Healthcare Provider Details

I. General information

NPI: 1073676268
Provider Name (Legal Business Name): DEBORA LEE BRYANT MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 04/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

395 PINE BROOK RD
BOULDER CO
80304-0435
US

IV. Provider business mailing address

395 PINE BROOK RD
BOULDER CO
80304-0435
US

V. Phone/Fax

Practice location:
  • Phone: 303-955-2468
  • Fax:
Mailing address:
  • Phone: 303-955-2468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR036072
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number721
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: