Provider Demographics
NPI:1144359795
Name:BRYAN, KELLY DEAN (LMSW, CAC-I)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:DEAN
Last Name:BRYAN
Suffix:
Gender:F
Credentials:LMSW, CAC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1402 WOODSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48708-5478
Mailing Address - Country:US
Mailing Address - Phone:989-895-5049
Mailing Address - Fax:
Practice Address - Street 1:6379 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:MI
Practice Address - Zip Code:48722-9566
Practice Address - Country:US
Practice Address - Phone:989-777-4357
Practice Address - Fax:989-777-7257
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801077320104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0996611OtherHEALTH PLUS OF MICHIGAN
MI1021439OtherMCLAREN