Provider Demographics
NPI:1912266297
Name:BRYAN MANION, LIFE COACH
Entity Type:Organization
Organization Name:BRYAN MANION, LIFE COACH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:MYLES
Authorized Official - Last Name:MANION
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-474-8455
Mailing Address - Street 1:PO BOX 934
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61824-0934
Mailing Address - Country:US
Mailing Address - Phone:217-474-8455
Mailing Address - Fax:
Practice Address - Street 1:206 N RANDOLPH ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-3949
Practice Address - Country:US
Practice Address - Phone:217-474-8455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-08
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.006836101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty