Provider Demographics
NPI:1033587696
Name:LEDFORD, BRYNNA CATHERINE WICTUM (MED)
Entity Type:Individual
Prefix:
First Name:BRYNNA
Middle Name:CATHERINE WICTUM
Last Name:LEDFORD
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1054 S DE ANZA BLVD # 105
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95129-3553
Mailing Address - Country:US
Mailing Address - Phone:408-673-1927
Mailing Address - Fax:
Practice Address - Street 1:1054 S DE ANZA BLVD # 105
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95129-3553
Practice Address - Country:US
Practice Address - Phone:408-673-1927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-11
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-16-21661103K00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst