Provider Demographics
NPI:1053549279
Name:BAILEY, BRYAN KEITH (LPC)
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:KEITH
Last Name:BAILEY
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1690 N LIMESTONE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-2652
Mailing Address - Country:US
Mailing Address - Phone:937-717-5591
Mailing Address - Fax:
Practice Address - Street 1:601 S EDWIN C MOSES BLVD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-3424
Practice Address - Country:US
Practice Address - Phone:937-734-8333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.0600602101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH10065Medicaid