Provider Demographics
NPI:1770868234
Name:BRYANT, ANGELIA SHAW (NCC CCMHC CHT LPCC-S)
Entity Type:Individual
Prefix:DR
First Name:ANGELIA
Middle Name:SHAW
Last Name:BRYANT
Suffix:
Gender:F
Credentials:NCC CCMHC CHT LPCC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2976 HIGHWAY 910
Mailing Address - Street 2:
Mailing Address - City:RUSSELL SPRINGS
Mailing Address - State:KY
Mailing Address - Zip Code:42642-8963
Mailing Address - Country:US
Mailing Address - Phone:270-566-1122
Mailing Address - Fax:
Practice Address - Street 1:2976 HIGHWAY 910
Practice Address - Street 2:SUITE B
Practice Address - City:RUSSELL SPRINGS
Practice Address - State:KY
Practice Address - Zip Code:42642-8963
Practice Address - Country:US
Practice Address - Phone:270-866-4753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-17
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY103409101YM0800X
KY0031101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty