Provider Demographics
NPI:1124041280
Name:PORT, BRYAN B (PSYD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:B
Last Name:PORT
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2046 LINCOLN ST # 2
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94709-2018
Mailing Address - Country:US
Mailing Address - Phone:510-883-1847
Mailing Address - Fax:
Practice Address - Street 1:2046 LINCOLN ST # 2
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94709-2018
Practice Address - Country:US
Practice Address - Phone:510-883-1847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19116103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL191160Medicare UPIN