Provider Demographics
NPI:1376257428
Name:HARRIS, BRYANT EDWARD (LICSW)
Entity Type:Individual
Prefix:
First Name:BRYANT
Middle Name:EDWARD
Last Name:HARRIS
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 CHURCHILL CT STE 140
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-6846
Mailing Address - Country:US
Mailing Address - Phone:706-442-4487
Mailing Address - Fax:
Practice Address - Street 1:700 CHURCHILL CT STE 140
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-6846
Practice Address - Country:US
Practice Address - Phone:470-231-8856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-12
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5218C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical