Provider Demographics
NPI:1821065921
Name:BRYANT, LISA HENDERSON (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:HENDERSON
Last Name:BRYANT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 MEDICAL PARK RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-8003
Mailing Address - Country:US
Mailing Address - Phone:803-255-3417
Mailing Address - Fax:803-255-3451
Practice Address - Street 1:15 MEDICAL PARK RD
Practice Address - Street 2:SUITE 300
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-8003
Practice Address - Country:US
Practice Address - Phone:803-255-3417
Practice Address - Fax:803-255-3451
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC135702084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Not Answered2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC135703Medicaid
SC135703Medicaid