Provider Demographics
NPI:1649536798
Name:BRYANT, MAVIS (BA)
Entity type:Individual
Prefix:
First Name:MAVIS
Middle Name:
Last Name:BRYANT
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4050 RIOMAR DR
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-5322
Mailing Address - Country:US
Mailing Address - Phone:321-634-6047
Mailing Address - Fax:321-634-6523
Practice Address - Street 1:4050 RIOMAR DR
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-5322
Practice Address - Country:US
Practice Address - Phone:321-634-6047
Practice Address - Fax:321-634-6523
Is Sole Proprietor?:No
Enumeration Date:2012-04-03
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker