Provider Demographics
NPI:1235547654
Name:PRINCE, BRIAN (MED, MSCE)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:PRINCE
Suffix:
Gender:M
Credentials:MED, MSCE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:837 W COLTER ST
Mailing Address - Street 2:APT. 51
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-2269
Mailing Address - Country:US
Mailing Address - Phone:602-621-6338
Mailing Address - Fax:
Practice Address - Street 1:837 W COLTER ST
Practice Address - Street 2:APT. 51
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-2269
Practice Address - Country:US
Practice Address - Phone:602-621-6338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-29
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4304852101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool