Healthcare Provider Details

I. General information

NPI: 1689082885
Provider Name (Legal Business Name): JOSEPH BRYANT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2014
Last Update Date: 07/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11960 WESTLINE INDUSTRIAL DR 201
SAINT LOUIS MO
63146-3209
US

IV. Provider business mailing address

11960 WESTLINE INDUSTRIAL DR 201
SAINT LOUIS MO
63146-3209
US

V. Phone/Fax

Practice location:
  • Phone: 314-819-0480
  • Fax: 314-275-7444
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: