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General NPI Number Information
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NPI Number | 1457846594
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Entity Type | Organization
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Legal Business Name | WILMA L. BRYANT PSYCHOTHERAPY LTD
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Dates
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Enumeration Date | 06/29/2018
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Last Update Date | 12/06/2024
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Provider Practice Location Address
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Address Line | 100 N CHESTNUT ST STE 229
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City | CHAMPAIGN
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State | IL
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Zip | 61820-4856
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Country | US
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Telephone | 217-637-7815
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Fax | 844-693-1411
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Provider Business Mailing Address
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Address Line | 2807 WOODHAVEN DR
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City | CHAMPAIGN
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State | IL
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Zip | 61822-7573
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Country | US
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Telephone | 217-637-7715
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Fax |
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Authorized Official
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Title or Position | PSYCHOTHERAPY
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Name | WILMA L. BRYANT
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Credential | LCSW
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Telephone | 217-637-7815
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | 149005877
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License Number State | IL
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