Provider Demographics
NPI:1194938571
Name:MASSENBURG, BRYANT ODELL (LCSW)
Entity type:Individual
Prefix:MR
First Name:BRYANT
Middle Name:ODELL
Last Name:MASSENBURG
Suffix:
Gender:M
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 HUEBNER RD
Mailing Address - Street 2:
Mailing Address - City:FT RILEY
Mailing Address - State:KS
Mailing Address - Zip Code:66442-4030
Mailing Address - Country:US
Mailing Address - Phone:757-535-6301
Mailing Address - Fax:
Practice Address - Street 1:650 HUEBNER RD
Practice Address - Street 2:
Practice Address - City:FT RILEY
Practice Address - State:KS
Practice Address - Zip Code:66442-4030
Practice Address - Country:US
Practice Address - Phone:757-535-6301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040065611041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical