Healthcare Provider Details

I. General information

NPI: 1801395819
Provider Name (Legal Business Name): MIRIYA MECHAE BRYANT MSW, LCSWA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2018
Last Update Date: 02/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6870 OLD WIRE RD
LAUREL HILL NC
28351-9718
US

IV. Provider business mailing address

6870 OLD WIRE RD
LAUREL HILL NC
28351-9718
US

V. Phone/Fax

Practice location:
  • Phone: 910-280-4255
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP011776
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: