Healthcare Provider Details

I. General information

NPI: 1073593968
Provider Name (Legal Business Name): TINA YVETTE BRYANT LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 A SECOND ST, SE
KIRTLAND AFB NM
87117-0001
US

IV. Provider business mailing address

2050 A SECOND ST, SE
KIRTLAND AFB NM
87117-0001
US

V. Phone/Fax

Practice location:
  • Phone: 505-846-3305
  • Fax: 505-846-3295
Mailing address:
  • Phone: 505-846-3305
  • Fax: 505-846-3295

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number32420
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: