Basic Information
Provider Information | |||||||||
NPI: | 1780893669 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRYANT | ||||||||
FirstName: | RUSSELL | ||||||||
MiddleName: | ALAN | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BRYANT | ||||||||
OtherFirstName: | RUSSELL | ||||||||
OtherMiddleName: | A. | ||||||||
OtherNamePrefix: | MR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LCSW | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 845347 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752845347 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2146450624 | ||||||||
FaxNumber: | 2146450078 | ||||||||
Practice Location | |||||||||
Address1: | 6363 FOREST PARK RD 7TH FL STE 749 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 753907046 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2146458500 | ||||||||
FaxNumber: | 2146483775 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/21/2007 | ||||||||
LastUpdateDate: | 06/01/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/01/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 50263 | TX | N |   | Behavioral Health & Social Service Providers | Social Worker |   | 1041C0700X | 1145 | AK | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 50263 | TX | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.