Provider Demographics
NPI:1700511987
Name:BRYAN, PETAGAYE (LMSW)
Entity Type:Individual
Prefix:
First Name:PETAGAYE
Middle Name:
Last Name:BRYAN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 BARNES AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-8907
Mailing Address - Country:US
Mailing Address - Phone:917-330-6447
Mailing Address - Fax:
Practice Address - Street 1:2175 WESTCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-4734
Practice Address - Country:US
Practice Address - Phone:718-829-6777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-20
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker