Provider Demographics
NPI:1104818764
Name:BRYANT, IVORY MYRICK (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:IVORY
Middle Name:MYRICK
Last Name:BRYANT
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MISS
Other - First Name:IVORY
Other - Middle Name:EUGENE
Other - Last Name:MYRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:545 OLD NORCROSS RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-3389
Mailing Address - Country:US
Mailing Address - Phone:678-377-2833
Mailing Address - Fax:678-377-2882
Practice Address - Street 1:545 OLD NORCROSS RD
Practice Address - Street 2:SUITE 100
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3389
Practice Address - Country:US
Practice Address - Phone:678-377-2833
Practice Address - Fax:678-377-2882
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006196235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA392229867AOtherACTIVE MEDICAID