Provider Demographics
NPI:1871241018
Name:BRYAN, RANDI D (LCSW)
Entity Type:Individual
Prefix:
First Name:RANDI
Middle Name:D
Last Name:BRYAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 HANKES RD
Mailing Address - Street 2:
Mailing Address - City:SUGAR GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60554-4300
Mailing Address - Country:US
Mailing Address - Phone:757-784-8295
Mailing Address - Fax:
Practice Address - Street 1:402 HANKES RD
Practice Address - Street 2:
Practice Address - City:SUGAR GROVE
Practice Address - State:IL
Practice Address - Zip Code:60554-4300
Practice Address - Country:US
Practice Address - Phone:757-784-8295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-16
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040127051041C0700X
IL1490243911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical