Provider Demographics
NPI:1942555982
Name:JAMES-BRYANT, VIDA MICHELE (COTA)
Entity Type:Individual
Prefix:
First Name:VIDA
Middle Name:MICHELE
Last Name:JAMES-BRYANT
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2324 NW 85 STREET
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33147
Mailing Address - Country:US
Mailing Address - Phone:754-224-8870
Mailing Address - Fax:
Practice Address - Street 1:1309 AVINGTON GLEN DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045
Practice Address - Country:US
Practice Address - Phone:754-224-8870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA000968172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker