Healthcare Provider Details

I. General information

NPI: 1770791188
Provider Name (Legal Business Name): CAROL BRYANT RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3506 GRATIOT AVE
DETROIT MI
48207-1830
US

IV. Provider business mailing address

20801 NORTHOME ST
SOUTHFIELD MI
48076-5260
US

V. Phone/Fax

Practice location:
  • Phone: 313-887-6757
  • Fax:
Mailing address:
  • Phone: 248-350-1733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number4704112086
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: