=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609246420
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KINGSLEY BRYANT LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2015
-----------------------------------------------------
Last Update Date | 12/06/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29 W LANCASTER AVE STE 303
-----------------------------------------------------
City | ARDMORE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19003-1408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-868-2026
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2383 HARMONYVILLE RD
-----------------------------------------------------
City | ELVERSON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19520-8975
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-868-2026
-----------------------------------------------------
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 | CW016251
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------