Provider Demographics
NPI:1659802858
Name:BRYANT, BERNESTINE
Entity Type:Individual
Prefix:
First Name:BERNESTINE
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 1:3876 NORTHSIDE DR APT 1201
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-2451
Mailing Address - Country:US
Mailing Address - Phone:478-775-0468
Mailing Address - Fax:
Practice Address - Street 1:940 GA HIGHWAY 96
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-2584
Practice Address - Country:US
Practice Address - Phone:478-988-1222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility