=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568919132
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRYAN SAFRANSKI MA LLP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2016
-----------------------------------------------------
Last Update Date | 02/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 34276 52ND STREET
-----------------------------------------------------
City | BANGOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49013-0177
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-655-3345
-----------------------------------------------------
Fax | 269-427-1012
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 177
-----------------------------------------------------
City | BANGOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49013-0177
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-655-3345
-----------------------------------------------------
Fax | 269-427-1012
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 6301009926
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 6361002723
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------