Provider Demographics
NPI:1700470473
Name:BRYAN, ANNIE
Entity Type:Individual
Prefix:
First Name:ANNIE
Middle Name:
Last Name:BRYAN
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 1:1217 CARTER RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-4602
Mailing Address - Country:US
Mailing Address - Phone:229-272-2541
Mailing Address - Fax:
Practice Address - Street 1:465 WINN WAY STE 130&140
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1753
Practice Address - Country:US
Practice Address - Phone:888-509-6368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician