Provider Demographics
NPI:1023744034
Name:PARMELLY, BRYCE C
Entity type:Individual
Prefix:
First Name:BRYCE
Middle Name:C
Last Name:PARMELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 141
Mailing Address - Street 2:
Mailing Address - City:LAGUNITAS
Mailing Address - State:CA
Mailing Address - Zip Code:94938-0141
Mailing Address - Country:US
Mailing Address - Phone:831-239-5749
Mailing Address - Fax:
Practice Address - Street 1:1480 LINCOLN AVE STE 8
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2085
Practice Address - Country:US
Practice Address - Phone:415-456-7724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-01
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
390200000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program