Provider Demographics
NPI:1891787255
Name:CONNELL, BRYAN EDWARD (PHD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:EDWARD
Last Name:CONNELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 PROSPERITY CHURCH RD
Mailing Address - Street 2:STE J
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-8100
Mailing Address - Country:US
Mailing Address - Phone:704-641-0273
Mailing Address - Fax:704-625-9182
Practice Address - Street 1:3020 PROSPERITY CHURCH RD
Practice Address - Street 2:STE J
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-8100
Practice Address - Country:US
Practice Address - Phone:704-641-0273
Practice Address - Fax:704-625-9182
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1681103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
61-00069OtherEVERCARE
NC0486JOtherBCBSNC
NC6000586Medicaid
NC6000586Medicaid