Provider Demographics
NPI:1942441639
Name:BRYAN, STEPHANIE M (LCSW, CAC III)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:M
Last Name:BRYAN
Suffix:
Gender:F
Credentials:LCSW, CAC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 55TH ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-1256
Mailing Address - Country:US
Mailing Address - Phone:303-397-0646
Mailing Address - Fax:303-443-9338
Practice Address - Street 1:1530 55TH ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-1256
Practice Address - Country:US
Practice Address - Phone:303-397-0646
Practice Address - Fax:303-443-9338
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-10
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2329101YA0400X
CO9892431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)