Provider Demographics
NPI:1649848706
Name:BRYANT, MARKEETA IMANI (LCSW)
Entity type:Individual
Prefix:
First Name:MARKEETA
Middle Name:IMANI
Last Name:BRYANT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 W BROAD ST # 17
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677-5258
Mailing Address - Country:US
Mailing Address - Phone:704-208-8111
Mailing Address - Fax:
Practice Address - Street 1:218 W BROAD ST # 17
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-5258
Practice Address - Country:US
Practice Address - Phone:704-208-8111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-15
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0151251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical