Provider Demographics
NPI:1538218326
Name:GOULET, BRYANT GERARDE (LMSW)
Entity type:Individual
Prefix:MR
First Name:BRYANT
Middle Name:GERARDE
Last Name:GOULET
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:659 S WAVERLY ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1651
Mailing Address - Country:US
Mailing Address - Phone:313-277-5742
Mailing Address - Fax:
Practice Address - Street 1:15370 LEVAN RD
Practice Address - Street 2:SUITE 2
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-1903
Practice Address - Country:US
Practice Address - Phone:734-744-0170
Practice Address - Fax:734-744-0171
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801034057104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker