Provider Demographics
NPI:1700568136
Name:BRYAN, RUSSELL STEWART (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:STEWART
Last Name:BRYAN
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2013 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-2772
Mailing Address - Country:US
Mailing Address - Phone:502-939-8195
Mailing Address - Fax:
Practice Address - Street 1:2013 LOCUST ST
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-2772
Practice Address - Country:US
Practice Address - Phone:502-939-8195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-04
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY66771041C0700X
IN34010095A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical