Provider Demographics
NPI:1063890408
Name:BRYANT, BENGIE
Entity type:Individual
Prefix:
First Name:BENGIE
Middle Name:
Last Name:BRYANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:951 OWLS CREEK LN
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-5839
Mailing Address - Country:US
Mailing Address - Phone:757-289-4529
Mailing Address - Fax:
Practice Address - Street 1:4520 HOLLAND OFFICE PARK
Practice Address - Street 2:SUITE 418
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-1145
Practice Address - Country:US
Practice Address - Phone:757-333-6580
Practice Address - Fax:757-333-6590
Is Sole Proprietor?:No
Enumeration Date:2015-05-18
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0710102236101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)