Provider Demographics
NPI:1861161432
Name:ANDERSON, BRYAN WAYNE (NCC)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:WAYNE
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 N 3RD AVE STE 330
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-6369
Mailing Address - Country:US
Mailing Address - Phone:208-242-3771
Mailing Address - Fax:
Practice Address - Street 1:151 N 3RD AVE STE 330
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-6369
Practice Address - Country:US
Practice Address - Phone:208-242-3771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health