Healthcare Provider Details

I. General information

NPI: 1720317969
Provider Name (Legal Business Name): CHEMARRA BRYANT MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2009
Last Update Date: 12/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

258 E GARRISON BLVD
GASTONIA NC
28054-0460
US

IV. Provider business mailing address

PO BOX 3984
GASTONIA NC
28054-0040
US

V. Phone/Fax

Practice location:
  • Phone: 704-861-8405
  • Fax: 704-865-0590
Mailing address:
  • Phone: 704-861-8405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7357
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: