Provider Demographics
NPI:1063804821
Name:DUCKHAM, BRYAN CHARLES (PHD, MSW, LCSW)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:CHARLES
Last Name:DUCKHAM
Suffix:
Gender:M
Credentials:PHD, MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12125 WOODCREST EXEC. DRIVE STE 110
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141
Mailing Address - Country:US
Mailing Address - Phone:314-275-8599
Mailing Address - Fax:314-275-8299
Practice Address - Street 1:12125 WOODCREST EXEC. DRIVE STE 110
Practice Address - Street 2:
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141
Practice Address - Country:US
Practice Address - Phone:314-275-8599
Practice Address - Fax:314-275-8299
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-03
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO366104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker