Basic Information
| Provider Information | |||||||||
| NPI: | 1730251968 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRYSON-BROCKMANN | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 222 STATION PLZ N | ||||||||
| Address2: | SUITE 611 | ||||||||
| City: | MINEOLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115013808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166634432 | ||||||||
| FaxNumber: | 5166634409 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 STATION PLZ N | ||||||||
| Address2: | SUITE 611 | ||||||||
| City: | MINEOLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115013808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166634432 | ||||||||
| FaxNumber: | 5166634409 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 103T00000X | 009669 | NY | X | Behavioral Health & Social Service Providers | Psychologist | 103TB0200X | 009669 | NY | X | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | 103TC0700X | 009669 | NY | X | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC2200X | 009669 | NY | X | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103TM1800X | 009669 | NY | X | Behavioral Health & Social Service Providers | Psychologist | Mental Retardation & Developmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | 0049693 | 01 | NY | GHI PPO | OTHER | 118426 | 01 | NY | VYTRA HEALTH PLAN | OTHER | VA2061 | 01 | NY | EMPIRE BLUECROSS BLUESHIE | OTHER | AS1545 | 01 | NY | OXFORD HEALTH PLANS | OTHER |