Provider Demographics
NPI:1730960741
Name:BRYANT, KATRINA RENEE (MS, LCAS)
Entity type:Individual
Prefix:MS
First Name:KATRINA
Middle Name:RENEE
Last Name:BRYANT
Suffix:
Gender:F
Credentials:MS, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1213 W MOREHEAD ST FL 5
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-5576
Mailing Address - Country:US
Mailing Address - Phone:704-325-8336
Mailing Address - Fax:704-325-8356
Practice Address - Street 1:5017 ELIZABETH RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-4534
Practice Address - Country:US
Practice Address - Phone:704-325-8336
Practice Address - Fax:704-825-8356
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-06
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities