=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619100831
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE OFFICE OF ADELE M. BRYANT, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2009
-----------------------------------------------------
Last Update Date | 09/04/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17127 OAK PARK AVE
-----------------------------------------------------
City | TINLEY PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60477-3405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-530-4589
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 410 N REED ST
-----------------------------------------------------
City | JOLIET
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60435-5968
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE PROPRIETOR
-----------------------------------------------------
Name | ADELE M. BRYANT
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 815-726-2546
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 180000741
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------