Provider Demographics
NPI:1932238516
Name:BRYANT, WILMA L (LCSW)
Entity Type:Individual
Prefix:MS
First Name:WILMA
Middle Name:L
Last Name:BRYANT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N CHESTNUT ST STE 229
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-4856
Mailing Address - Country:US
Mailing Address - Phone:217-637-7815
Mailing Address - Fax:
Practice Address - Street 1:100 N CHESTNUT ST STE 229
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-4856
Practice Address - Country:US
Practice Address - Phone:217-637-7815
Practice Address - Fax:844-693-1411
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490058771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001007627OtherBLUE CROSS BLUE SHIELD
IL6447860006Medicare NSC
ILIL3270345Medicare PIN