Basic Information
| Provider Information | |||||||||
| NPI: | 1619066990 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRYANT | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | JOHNSON | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | M.A./LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3840 N THOMAS RD | ||||||||
| Address2: | |||||||||
| City: | FREELAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486238816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897810471 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2603 W WACKERLY ST | ||||||||
| Address2: | SUITE, A | ||||||||
| City: | MIDLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486406903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9896312320 | ||||||||
| FaxNumber: | 9896319903 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 101YM0800X | 6401006769 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.