MEDICARE: DERECA BRYANT LCSWA

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	1041C0700X	Clinical Social Worker	P021970	NC

General Provider Information

NPI Number	:	1629860325
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DERECA BRYANT LCSWA

Provider Business Mailing Address
First Line	:	1817 ALEXANDER HIGHLANDS DR APT 204
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-5524
Country	:	US
Telephone Number	:	704-488-1389
Fax Number	:

Provider Business Practice Location Address
First Line	:	1817 ALEXANDER HIGHLANDS DR APT 204
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-5524
Country	:	US
Telephone Number	:	704-488-1389
Fax Number	:

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

Provider Enumeration Date	:	05/19/2025
Last Update Date	:	05/19/2025

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