Healthcare Provider Details

I. General information

NPI: 1518335611
Provider Name (Legal Business Name): MARCUS BRYANT LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2015
Last Update Date: 09/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12110 CLAYTON RD
SAINT LOUIS MO
63131-2516
US

IV. Provider business mailing address

206 PADDLEWHEEL DR
FLORISSANT MO
63033-6300
US

V. Phone/Fax

Practice location:
  • Phone: 314-989-7200
  • Fax:
Mailing address:
  • Phone: 785-249-5206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number2007024804
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: