Provider Demographics
NPI:1619407798
Name:BRYANT, LISA DEEANN (PT, DPT, CEAS)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DEEANN
Last Name:BRYANT
Suffix:
Gender:F
Credentials:PT, DPT, CEAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 DIAMONDBACK LN
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-6060
Mailing Address - Country:US
Mailing Address - Phone:601-316-7221
Mailing Address - Fax:601-202-3063
Practice Address - Street 1:363 HIGHLAND COLONY PKWY
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-6035
Practice Address - Country:US
Practice Address - Phone:601-398-0171
Practice Address - Fax:601-398-0983
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT5093225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist