Basic Information
| Provider Information | |||||||||
| NPI: | 1508907999 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRYANT | ||||||||
| FirstName: | DAMONICA | ||||||||
| MiddleName: | COLLEEN | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8400 LOUISIANA ST | ||||||||
| Address2: | |||||||||
| City: | MERRILLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464106385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197571928 | ||||||||
| FaxNumber: | 2197571950 | ||||||||
| Practice Location | |||||||||
| Address1: | 5900 HOHMAN AVE | ||||||||
| Address2: | |||||||||
| City: | HAMMOND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463202423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199310427 | ||||||||
| FaxNumber: | 2199375808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2007 | ||||||||
| LastUpdateDate: | 05/25/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 34004356A | IN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 000000533287 | 01 | IN | ANTHEM BC/BS | OTHER |