Provider Demographics
NPI:1841214079
Name:BRYAN, MARILYN M (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:M
Last Name:BRYAN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1288
Mailing Address - Street 2:580 FARRINGDOM STREET
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28359
Mailing Address - Country:US
Mailing Address - Phone:910-671-9629
Mailing Address - Fax:910-671-9630
Practice Address - Street 1:580 FARRINGDOM STREET
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358
Practice Address - Country:US
Practice Address - Phone:910-671-9629
Practice Address - Fax:910-671-9630
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5318235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7412021Medicaid