Healthcare Provider Details

I. General information

NPI: 1124827654
Provider Name (Legal Business Name): BARRY KELVIN BRYANT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2025
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 BRIDGE ST NW
GRAND RAPIDS MI
49504-5367
US

IV. Provider business mailing address

1995 SHINING TREE DR NE
BELMONT MI
49306-8836
US

V. Phone/Fax

Practice location:
  • Phone: 616-805-3660
  • Fax: 616-805-3631
Mailing address:
  • Phone: 616-690-1768
  • Fax: 616-690-1768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6451023740
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: