MEDICARE: KATHRYN BRYAN PHD

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	103TC1900X	Counseling Psychologist	PSY004313	GA

General Provider Information

NPI Number	:	1679052351
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHRYN BRYAN PHD

Provider Business Mailing Address
First Line	:	760 DALEROSE AVE
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30030-3936
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	814 JUNIPER ST NE STE 201
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30308-1300
Country	:	US
Telephone Number	:	404-965-5843
Fax Number	:

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

Provider Enumeration Date	:	08/13/2018
Last Update Date	:	09/09/2019

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