Provider Demographics
NPI:1801436944
Name:BRYANT, KENNETH WAYNE JR (LPC A)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:WAYNE
Last Name:BRYANT
Suffix:JR
Gender:M
Credentials:LPC A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 NASH ST W STE 200
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-3761
Mailing Address - Country:US
Mailing Address - Phone:252-360-1489
Mailing Address - Fax:252-991-6570
Practice Address - Street 1:405 NASH ST W STE 200
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-3761
Practice Address - Country:US
Practice Address - Phone:252-360-1489
Practice Address - Fax:252-991-6570
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-07
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA15365101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health