Healthcare Provider Details

I. General information

NPI: 1477688679
Provider Name (Legal Business Name): ELIZABETH BRYANT PHD,LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 SPRINGS BLVD
ELEPHANT BUTTE NM
87935
US

IV. Provider business mailing address

PO BOX 1024
TRUTH OR CONSEQUENCES NM
87901-1024
US

V. Phone/Fax

Practice location:
  • Phone: 505-740-4224
  • Fax: 505-744-0078
Mailing address:
  • Phone: 505-740-4224
  • Fax: 505-744-0078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number2996
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: