Basic Information
| Provider Information | |||||||||
| NPI: | 1962588186 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRYANT | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | GAIL | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1818 WHITEHEAD | ||||||||
| Address2: | |||||||||
| City: | SOUTHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 38671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622807570 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3810 WINCHESTER | ||||||||
| Address2: | SOUTHEAST MENTAL HEALTH CENTER | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381189007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9013691420 | ||||||||
| FaxNumber: | 9013691433 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | TN | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.