Provider Demographics
NPI:1801243019
Name:BRYAN, TALIA (LCSW)
Entity type:Individual
Prefix:
First Name:TALIA
Middle Name:
Last Name:BRYAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 POTOMAC AVE STE B
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22301-3064
Mailing Address - Country:US
Mailing Address - Phone:757-358-1771
Mailing Address - Fax:
Practice Address - Street 1:4809 EISENHOWER AVE STE B
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-4832
Practice Address - Country:US
Practice Address - Phone:757-358-1771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040088521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical