Healthcare Provider Details

I. General information

NPI: 1144359795
Provider Name (Legal Business Name): KELLY DEAN BRYAN LMSW, CAC-I
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6379 DIXIE HWY
BRIDGEPORT MI
48722-9566
US

IV. Provider business mailing address

1402 WOODSIDE AVE
BAY CITY MI
48708-5478
US

V. Phone/Fax

Practice location:
  • Phone: 989-777-4357
  • Fax: 989-777-7257
Mailing address:
  • Phone: 989-895-5049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801077320
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: