Active NPI
Bryan Edward Connell, PHD
- Psychologist
- Charlotte, NC
National Provider Identifier
1891787255
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Psychologist
- License
- 1681
- Practice address
- 3020 Prosperity Church Rd
Ste J
Charlotte, NC 28269-8100 - Phone
- (704) 641-0273
- Fax
- (704) 625-9182
- NPI assigned
- Aug 22, 2005
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Psychologist | 103T00000X | 1681 | NC | Primary |
Addresses
Primary practice location
3020 Prosperity Church Rd
Ste J
Charlotte, NC 28269-8100
Mailing address
3020 Prosperity Church Rd
Ste J
Charlotte, NC 28269-8100
Phone (704) 641-0273
Other identifiers 3
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 61-00069 | Other | EVERCARE | |
| 0486J | Other | NC | BCBSNC |
| 6000586 | Medicaid | NC |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in NC
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: No
- Power mobility devices: No
- Hospice: No
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20040622001334 | NC | Practitioner - Clinical Psychologist | 4486639556 | Practice locations: Albemarle, NC; Charlotte, NC; Concord, NC; Davidson, NC |
Care Compare profile
Medicare Care Compare- Specialty
- Clinical Psychologist
- Education
- Other, 1990
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
Practice addresses (Care Compare)
11230 Ballantyne Trace CT
Charlotte, NC 28277-2791
Phone (704) 641-0273
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 1681 | NC | MD | Addiction (Substance Use Disorder) Counselor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1124668800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1529884800000",
"number": "1891787255",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "3020 PROSPERITY CHURCH RD",
"address_2": "STE J",
"city": "CHARLOTTE",
"state": "NC",
"postal_code": "282698100",
"telephone_number": "704-641-0273",
"fax_number": "704-625-9182"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3020 PROSPERITY CHURCH RD",
"address_2": "STE J",
"city": "CHARLOTTE",
"state": "NC",
"postal_code": "282698100",
"telephone_number": "704-641-0273",
"fax_number": "704-625-9182"
}
],
"practiceLocations": [],
"basic": {
"last_name": "CONNELL",
"first_name": "BRYAN",
"middle_name": "EDWARD",
"credential": "PHD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2005-08-22",
"last_updated": "2018-06-25",
"status": "A"
},
"taxonomies": [
{
"code": "103T00000X",
"taxonomy_group": "",
"desc": "Psychologist",
"state": "NC",
"license": "1681",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "EVERCARE",
"identifier": "61-00069",
"state": null
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BCBSNC",
"identifier": "0486J",
"state": "NC"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "6000586",
"state": "NC"
}
],
"endpoints": [],
"other_names": []
}Other providers in Charlotte, NC
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 25, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.