Provider Demographics
NPI:1316578958
Name:BRYANT, LISA IVEY (MS CCCSLP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:IVEY
Last Name:BRYANT
Suffix:
Gender:F
Credentials:MS CCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1511 WESTPOINTE DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-8421
Mailing Address - Country:US
Mailing Address - Phone:252-412-5509
Mailing Address - Fax:
Practice Address - Street 1:100 HICKORY ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-1674
Practice Address - Country:US
Practice Address - Phone:252-412-5509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-02
Last Update Date:2020-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2660235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist