Provider Demographics
NPI:1073985271
Name:BRYSON, ROBERT
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:BRYSON
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 1:52040 AVENIDA DIAZ
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-3226
Mailing Address - Country:US
Mailing Address - Phone:760-404-5743
Mailing Address - Fax:
Practice Address - Street 1:52040 AVENIDA DIAZ
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-3226
Practice Address - Country:US
Practice Address - Phone:760-404-5743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-27
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health