Healthcare Provider Details

I. General information

NPI: 1568919132
Provider Name (Legal Business Name): BRYAN SAFRANSKI MA LLP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 02/22/2022
Certification Date: 02/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34276 52ND STREET
BANGOR MI
49013-0177
US

IV. Provider business mailing address

PO BOX 177
BANGOR MI
49013-0177
US

V. Phone/Fax

Practice location:
  • Phone: 269-655-3345
  • Fax: 269-427-1012
Mailing address:
  • Phone: 269-655-3345
  • Fax: 269-427-1012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301009926
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6361002723
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: