Provider Demographics
NPI:1558342063
Name:BRYANT, MAVIS ANNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MAVIS
Middle Name:ANNE
Last Name:BRYANT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 TEAGUE DRIVE
Mailing Address - Street 2:SUITE 502
Mailing Address - City:SHERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75090-2656
Mailing Address - Country:US
Mailing Address - Phone:903-892-4466
Mailing Address - Fax:903-892-2634
Practice Address - Street 1:1800 TEAGUE DRIVE
Practice Address - Street 2:SUITE 502
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75090-2656
Practice Address - Country:US
Practice Address - Phone:903-892-4466
Practice Address - Fax:903-892-2634
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25035103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX034974801Medicaid
R08870Medicare UPIN
00N24CMedicare ID - Type Unspecified