=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093049017
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AJA N BRYANT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2009
-----------------------------------------------------
Last Update Date | 12/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2850 MESA VERDE DR E STE H
-----------------------------------------------------
City | COSTA MESA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92626-4857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-730-3660
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2850 MESA VERDE DR E STE H
-----------------------------------------------------
City | COSTA MESA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92626-4857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-730-3660
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LCSW66076
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------