Provider Demographics
NPI:1942500517
Name:OSBORN, BRYAN
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:OSBORN
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 1:11311 19TH AVE SE APT A106
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-5102
Mailing Address - Country:US
Mailing Address - Phone:509-859-2937
Mailing Address - Fax:
Practice Address - Street 1:11311 19TH AVE SE APT A106
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-5102
Practice Address - Country:US
Practice Address - Phone:509-859-2937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-28
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60187838101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor