MEDICARE: MRS. QUINICKA BRYANT-GHANT MSW, BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor
2	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1518216290
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. QUINICKA BRYANT-GHANT MSW, BCBA

Provider Business Mailing Address
First Line	:	300 INTERNATIONAL PKWY STE 200
Second Line	:
City	:	LAKE MARY
State	:	FL
Zip	:	32746-5028
Country	:	US
Telephone Number	:	866-610-0580
Fax Number	:	407-588-6294

Provider Business Practice Location Address
First Line	:	1237 AUGUSTA AVE
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30901-3201
Country	:	US
Telephone Number	:	762-685-4340
Fax Number	:	762-585-9965

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/10/2012
Last Update Date	:	06/10/2022

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