Healthcare Provider Details

I. General information

NPI: 1083172217
Provider Name (Legal Business Name): MONICA BRYAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2019
Last Update Date: 10/31/2024
Certification Date: 10/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 SARGENT DRIVE
FREDERICKTOWN MO
63645-7526
US

IV. Provider business mailing address

600 SARGENT DRIVE
FREDERICKTOWN MO
63645-7526
US

V. Phone/Fax

Practice location:
  • Phone: 573-783-4400
  • Fax:
Mailing address:
  • Phone: 573-783-4400
  • Fax: 573-634-3105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2024041912
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: