Provider Demographics
NPI:1023139508
Name:CRISP, BRYAN (LMFT, BCBA)
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:
Last Name:CRISP
Suffix:
Gender:M
Credentials:LMFT, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 LYNNDALE COURT
Mailing Address - Street 2:SUITE A
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-5436
Mailing Address - Country:US
Mailing Address - Phone:252-413-8890
Mailing Address - Fax:252-756-7533
Practice Address - Street 1:620 LYNNDALE COURT
Practice Address - Street 2:SUITE A
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-5436
Practice Address - Country:US
Practice Address - Phone:252-413-8890
Practice Address - Fax:252-756-7533
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1169101Y00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC208684051OtherEIN NUMBER