Provider Demographics
NPI:1902891294
Name:BRYANT-MOBLEY, PHYLLIS MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:MARIE
Last Name:BRYANT-MOBLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1735 SAINT JULIAN PL STE 102
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2402
Mailing Address - Country:US
Mailing Address - Phone:803-497-9611
Mailing Address - Fax:803-764-2003
Practice Address - Street 1:1735 SAINT JULIAN PL STE 102
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2402
Practice Address - Country:US
Practice Address - Phone:803-497-9611
Practice Address - Fax:803-764-2003
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC207982084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC207984Medicaid
SC207984Medicaid