Provider Demographics
NPI:1407878663
Name:BRYANT, ANNETTE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:ANNETTE
Middle Name:
Last Name:BRYANT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ANNETTE
Other - Middle Name:
Other - Last Name:BRYANT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:113 WOODSTONE DR
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183-8319
Mailing Address - Country:US
Mailing Address - Phone:601-831-4402
Mailing Address - Fax:601-206-0672
Practice Address - Street 1:1107 OPENWOOD ST
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183
Practice Address - Country:US
Practice Address - Phone:601-831-4402
Practice Address - Fax:601-206-0672
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC65821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08000025Medicaid
MS302I801727OtherMEDICARE PTAN