Provider Demographics
NPI:1356974091
Name:BRYAN, MARK F
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:F
Last Name:BRYAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 AVON ST APT 3
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01880-2585
Mailing Address - Country:US
Mailing Address - Phone:781-568-9001
Mailing Address - Fax:
Practice Address - Street 1:37 WATER ST
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:MA
Practice Address - Zip Code:01880-3058
Practice Address - Country:US
Practice Address - Phone:781-851-2648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-21
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health