Healthcare Provider Details

I. General information

NPI: 1053549279
Provider Name (Legal Business Name): BRYAN KEITH BAILEY LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2009
Last Update Date: 11/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 S EDWIN C MOSES BLVD
DAYTON OH
45417-3424
US

IV. Provider business mailing address

1690 N LIMESTONE ST
SPRINGFIELD OH
45503-2652
US

V. Phone/Fax

Practice location:
  • Phone: 937-734-8333
  • Fax:
Mailing address:
  • Phone: 937-717-5591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC.0600602
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC.0600602
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: