MEDICARE: STACIE ROBYN BRYANT LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	2007024145	MO

General Provider Information

NPI Number	:	1548459605
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACIE ROBYN BRYANT LCSW

Provider Business Mailing Address
First Line	:	1504 S GRAND BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63104-1304
Country	:	US
Telephone Number	:	314-531-1770
Fax Number	:	314-771-8485

Provider Business Practice Location Address
First Line	:	1504 S GRAND BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63104-1304
Country	:	US
Telephone Number	:	314-531-1770
Fax Number	:	314-771-8485

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/15/2007
Last Update Date	:	10/15/2007

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