MEDICARE: MR. HANNIBAL BRYAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	640601121	NY
2	103K00000X	Behavior Analyst	1-21-51123	CT

General Provider Information

NPI Number	:	1578827515
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. HANNIBAL BRYAN

Provider Business Mailing Address
First Line	:	373 S WILLOW ST STE 266
Second Line	:
City	:	MANCHESTER
State	:	NH
Zip	:	03103-5751
Country	:	US
Telephone Number	:	877-315-8080
Fax Number	:

Provider Business Practice Location Address
First Line	:	373 S WILLOW ST STE 266
Second Line	:
City	:	MANCHESTER
State	:	NH
Zip	:	03103-5751
Country	:	US
Telephone Number	:	877-315-8080
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/25/2012
Last Update Date	:	05/09/2022

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