Provider Demographics
NPI:1285919464
Name:BRYAN, ANGELA
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:BRYAN
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 1:703 W HOUSATONIC ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01201-6678
Mailing Address - Country:US
Mailing Address - Phone:413-443-7219
Mailing Address - Fax:
Practice Address - Street 1:703 W HOUSATONIC ST
Practice Address - Street 2:SUITE 206
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-6678
Practice Address - Country:US
Practice Address - Phone:413-443-7219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1306839Medicaid