Provider Demographics
NPI:1184133241
Name:BRYANT, ROBERT LEE (BA, MS, PHD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:LEE
Last Name:BRYANT
Suffix:
Gender:M
Credentials:BA, MS, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1037 FAYETTE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46816-3610
Mailing Address - Country:US
Mailing Address - Phone:260-447-4970
Mailing Address - Fax:
Practice Address - Street 1:1037 FAYETTE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46816-3610
Practice Address - Country:US
Practice Address - Phone:260-447-4970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39000382A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health