Provider Demographics
NPI:1790188407
Name:BRYANT, SHANNON (APSW)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BRYANT
Suffix:
Gender:M
Credentials:APSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9012 WEST LAWRENCE AVENUE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53225
Mailing Address - Country:US
Mailing Address - Phone:414-322-5136
Mailing Address - Fax:
Practice Address - Street 1:9012 W LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53225-5039
Practice Address - Country:US
Practice Address - Phone:414-322-5136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-08
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI129400-121101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health