Healthcare Provider Details

I. General information

NPI: 1487713772
Provider Name (Legal Business Name): PAMELA RATHBUN BRYANT L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5412 GLENSIDE DR STE B
RICHMOND VA
23228-3995
US

IV. Provider business mailing address

5412 GLENSIDE DR STE B
RICHMOND VA
23228-3995
US

V. Phone/Fax

Practice location:
  • Phone: 804-741-4300
  • Fax: 804-741-5300
Mailing address:
  • Phone: 804-741-4300
  • Fax: 804-741-5300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0904003425
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: