1104119015 NPI number — DR. CARMEN MELANIE BRYANT M.A., ED. D., LMHC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104119015 NPI number — DR. CARMEN MELANIE BRYANT M.A., ED. D., LMHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRYANT
Provider First Name:
CARMEN
Provider Middle Name:
MELANIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.A., ED. D., LMHC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CLAYTON
Provider Other First Name:
CARMEN
Provider Other Middle Name:
MELANIE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.A., ED.D., LMHC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104119015
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 45549
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98448
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-414-4796
Provider Business Mailing Address Fax Number:
253-292-2039

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4301 S PINE ST STE 78
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98409-7252
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-414-4796
Provider Business Practice Location Address Fax Number:
253-292-2039
Provider Enumeration Date:
05/25/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  LH60411457 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2040276 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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