Basic Information
| Provider Information | |||||||||
| NPI: | 1003183567 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRYANT | ||||||||
| FirstName: | VIVIAN | ||||||||
| MiddleName: | DELORES | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRYANT | ||||||||
| OtherFirstName: | V | ||||||||
| OtherMiddleName: | DELORES | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1551 FORUM PL | ||||||||
| Address2: | BUILDING 400 D & E | ||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334012319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616168411 | ||||||||
| FaxNumber: | 5616168412 | ||||||||
| Practice Location | |||||||||
| Address1: | 1551 FORUM PL | ||||||||
| Address2: | BUILDING 400 D & E | ||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334012319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616168411 | ||||||||
| FaxNumber: | 5616168412 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2011 | ||||||||
| LastUpdateDate: | 11/28/2011 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.