Provider Demographics
NPI:1447773551
Name:BRYANT, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BRYANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5108 REAGAN DR STE 5
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28206-1394
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5104 REAGAN DR
Practice Address - Street 2:STE 5
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28206
Practice Address - Country:US
Practice Address - Phone:704-596-0505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-20
Last Update Date:2017-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA13067101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health