Provider Demographics
NPI:1104192996
Name:ELDRED, BRIAN WILLIAM (MS)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:WILLIAM
Last Name:ELDRED
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1583 RICHANDAVE AVE
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92019-2574
Mailing Address - Country:US
Mailing Address - Phone:619-368-4117
Mailing Address - Fax:619-462-2465
Practice Address - Street 1:4215 SPRING ST
Practice Address - Street 2:SUITE 215
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-7965
Practice Address - Country:US
Practice Address - Phone:619-462-2277
Practice Address - Fax:619-462-2465
Is Sole Proprietor?:No
Enumeration Date:2012-03-27
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF64600106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist