Healthcare Provider Details

I. General information

NPI: 1457274268
Provider Name (Legal Business Name): AMANDA BRYANT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 E MAIN ST
CLINTON NC
28328-4029
US

IV. Provider business mailing address

107 PAYTON DANIELS RD
ROSEBORO NC
28382-7176
US

V. Phone/Fax

Practice location:
  • Phone: 910-890-5434
  • Fax:
Mailing address:
  • Phone: 910-890-5434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA23104
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: