Healthcare Provider Details

I. General information

NPI: 1073119764
Provider Name (Legal Business Name): BRYANT MITCHELL KEITH LMFT; SB-LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2020
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CENTER ST STE 2B
SOUTHINGTON CT
06489-3102
US

IV. Provider business mailing address

1 CENTER ST STE 2B
SOUTHINGTON CT
06489-3102
US

V. Phone/Fax

Practice location:
  • Phone: 203-980-6089
  • Fax:
Mailing address:
  • Phone: 203-980-6089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number2831
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: