Provider Demographics
NPI:1831603927
Name:BRYANT, ESTEFANIA (MA)
Entity type:Individual
Prefix:
First Name:ESTEFANIA
Middle Name:
Last Name:BRYANT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 MOCKINGBIRD DR
Mailing Address - Street 2:
Mailing Address - City:TIJERAS
Mailing Address - State:NM
Mailing Address - Zip Code:87059-8232
Mailing Address - Country:US
Mailing Address - Phone:505-573-5407
Mailing Address - Fax:
Practice Address - Street 1:2632 PENNSYLVANIA ST NE STE E
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-3650
Practice Address - Country:US
Practice Address - Phone:505-573-5407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-28
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT-0192991101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health