Provider Demographics
NPI:1922602408
Name:BRYSON, KELLIE DAWN
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:DAWN
Last Name:BRYSON
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 1:9777 HIGHWAY 41
Mailing Address - Street 2:
Mailing Address - City:RINGGOLD
Mailing Address - State:GA
Mailing Address - Zip Code:30736-8682
Mailing Address - Country:US
Mailing Address - Phone:706-264-8509
Mailing Address - Fax:
Practice Address - Street 1:2826 AMICOLA HWY
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37406
Practice Address - Country:US
Practice Address - Phone:833-825-5246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-25
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA222118473583Medicaid