Provider Demographics
NPI:1366788093
Name:BRYANT, CLAUDETTE
Entity type:Individual
Prefix:
First Name:CLAUDETTE
Middle Name:
Last Name:BRYANT
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:P O BOX 284
Mailing Address - Street 2:2810 MC FADDEN COURT
Mailing Address - City:MULLINS
Mailing Address - State:SC
Mailing Address - Zip Code:29574
Mailing Address - Country:US
Mailing Address - Phone:843-774-6591
Mailing Address - Fax:843-774-1409
Practice Address - Street 1:204 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:SC
Practice Address - Zip Code:29536-3304
Practice Address - Country:US
Practice Address - Phone:843-774-6591
Practice Address - Fax:843-774-1409
Is Sole Proprietor?:No
Enumeration Date:2012-12-28
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1111011101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)