Provider Demographics
NPI:1962596213
Name:BRYANT, KENDRA L (PHD, ABPP-CN)
Entity type:Individual
Prefix:DR
First Name:KENDRA
Middle Name:L
Last Name:BRYANT
Suffix:
Gender:F
Credentials:PHD, ABPP-CN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1084
Mailing Address - Street 2:
Mailing Address - City:ROCKLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04841-1084
Mailing Address - Country:US
Mailing Address - Phone:207-594-2952
Mailing Address - Fax:
Practice Address - Street 1:120 TILLSON AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:ROCKLAND
Practice Address - State:ME
Practice Address - Zip Code:04841-3451
Practice Address - Country:US
Practice Address - Phone:207-594-2952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS1009103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME039230OtherANTHEM BCBS
ME209580000Medicaid
MEMM8448Medicare PIN