MEDICARE: CARSON BRYAN JD, PRSS

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	175T00000X	Peer Specialist	21-971	WV

General Provider Information

NPI Number	:	1841944402
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARSON BRYAN JD, PRSS

Provider Business Mailing Address
First Line	:	2333 MACCORKLE AVE
Second Line	:
City	:	SAINT ALBANS
State	:	WV
Zip	:	25177-2073
Country	:	US
Telephone Number	:	681-205-8548
Fax Number	:	855-888-9316

Provider Business Practice Location Address
First Line	:	2333 MACCORKLE AVE
Second Line	:
City	:	SAINT ALBANS
State	:	WV
Zip	:	25177-2073
Country	:	US
Telephone Number	:	681-205-8548
Fax Number	:	855-888-9316

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

Provider Enumeration Date	:	02/11/2022
Last Update Date	:	02/11/2022

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