Provider Demographics
NPI:1942474564
Name:BRYANT, GABRIELLA SELENE
Entity Type:Individual
Prefix:MRS
First Name:GABRIELLA
Middle Name:SELENE
Last Name:BRYANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5009 W OUTER DR
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-1342
Mailing Address - Country:US
Mailing Address - Phone:313-342-7070
Mailing Address - Fax:
Practice Address - Street 1:30200 TELEGRAPH RD
Practice Address - Street 2:402
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-4502
Practice Address - Country:US
Practice Address - Phone:248-644-3200
Practice Address - Fax:248-644-3211
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013330103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical