Healthcare Provider Details

I. General information

NPI: 1386553550
Provider Name (Legal Business Name): WATISHA BRYANT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 W CAMPBELLTON ST
FAIRBURN GA
30213-1219
US

IV. Provider business mailing address

830 CARLL CT
PALMETTO GA
30268-1150
US

V. Phone/Fax

Practice location:
  • Phone: 770-742-0249
  • Fax:
Mailing address:
  • Phone: 770-742-0249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: