Basic Information
| Provider Information | |||||||||
| NPI: | 1376877738 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRYANT | ||||||||
| FirstName: | ANN | ||||||||
| MiddleName: | LAKE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 148 N HUMPHREY AVE | ||||||||
| Address2: | APT C1 | ||||||||
| City: | OAK PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 603022540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7089487193 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6918 WINDSOR AVE | ||||||||
| Address2: | |||||||||
| City: | BERWYN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604023334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087455277 | ||||||||
| FaxNumber: | 7087954834 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2009 | ||||||||
| LastUpdateDate: | 10/01/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.