Provider Demographics
NPI:1043826134
Name:BRYANT, KEVIN LEE
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:LEE
Last Name:BRYANT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94607-3807
Mailing Address - Country:US
Mailing Address - Phone:510-268-7814
Mailing Address - Fax:510-268-2631
Practice Address - Street 1:400 BROADWAY
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94607-3807
Practice Address - Country:US
Practice Address - Phone:510-268-7814
Practice Address - Fax:510-268-2631
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator