Provider Demographics
NPI:1881166999
Name:BRYANT-WALES, AILEEN M (LPCC, TCADC)
Entity type:Individual
Prefix:MRS
First Name:AILEEN
Middle Name:M
Last Name:BRYANT-WALES
Suffix:
Gender:F
Credentials:LPCC, TCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12321 DOMINION WAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-4487
Mailing Address - Country:US
Mailing Address - Phone:502-417-9799
Mailing Address - Fax:
Practice Address - Street 1:2133 W MARKET ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40212-1532
Practice Address - Country:US
Practice Address - Phone:502-384-5807
Practice Address - Fax:502-384-5807
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-31
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY245650101YP2500X
KY241211101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100594570Medicaid