Provider Demographics
NPI:1710408281
Name:LECLAIRE, BRYAN
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:
Last Name:LECLAIRE
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 1:522 N BLOODWORTH ST
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-1226
Mailing Address - Country:US
Mailing Address - Phone:312-401-7572
Mailing Address - Fax:
Practice Address - Street 1:3725 NATIONAL DR STE 220
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-4879
Practice Address - Country:US
Practice Address - Phone:919-781-8370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-05
Last Update Date:2017-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0116151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical