MEDICARE: BRYAN EDWARD CONNELL PHD

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	103T00000X	Psychologist	1681	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	61-00069	OTHER		EVERCARE
2	0486J	OTHER	NC	BCBSNC
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1891787255
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRYAN EDWARD CONNELL PHD

Provider Business Mailing Address
First Line	:	3020 PROSPERITY CHURCH RD
Second Line	:	STE J
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-8100
Country	:	US
Telephone Number	:	704-641-0273
Fax Number	:	704-625-9182

Provider Business Practice Location Address
First Line	:	3020 PROSPERITY CHURCH RD
Second Line	:	STE J
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-8100
Country	:	US
Telephone Number	:	704-641-0273
Fax Number	:	704-625-9182

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

Provider Enumeration Date	:	08/22/2005
Last Update Date	:	06/25/2018

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Directions to “ BRYAN EDWARD CONNELL PHD” Practice Location

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