Provider Demographics
NPI:1588201370
Name:BRYANTLORD, JUANETHEA (MCHWC)
Entity type:Individual
Prefix:
First Name:JUANETHEA
Middle Name:
Last Name:BRYANTLORD
Suffix:
Gender:
Credentials:MCHWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 VARDEN DR STE A
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29803-5275
Mailing Address - Country:US
Mailing Address - Phone:803-226-0236
Mailing Address - Fax:803-226-0335
Practice Address - Street 1:35 VARDEN DR STE A
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29803-5275
Practice Address - Country:US
Practice Address - Phone:803-226-0236
Practice Address - Fax:803-226-0333
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-29
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003227886BMedicaid
GA003230056AMedicaid
GA003227886AMedicaid
SCEX1856Medicaid