Basic Information
| Provider Information | |||||||||
| NPI: | 1629378013 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRYANT | ||||||||
| FirstName: | AARON | ||||||||
| MiddleName: | BRUCE | ||||||||
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| Credential: | CSW, LSUDC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 65232 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841650232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019796995 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 450 S 900 E | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841022981 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015321850 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2010 | ||||||||
| LastUpdateDate: | 01/04/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 7099669-6005 | UT | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 104100000X | 7099669-3503 | UT | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 828282 | 05 | UT | MEDICAID |