Healthcare Provider Details

I. General information

NPI: 1538218326
Provider Name (Legal Business Name): BRYANT GERARDE GOULET LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15370 LEVAN RD SUITE 2
LIVONIA MI
48154-1903
US

IV. Provider business mailing address

659 S WAVERLY ST
DEARBORN MI
48124-1651
US

V. Phone/Fax

Practice location:
  • Phone: 734-744-0170
  • Fax: 734-744-0171
Mailing address:
  • Phone: 313-277-5742
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801034057
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: