Provider Demographics
NPI:1265009898
Name:DE VALLE, BRYAN
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:DE VALLE
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:PO BOX 36
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-0003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:221 W MAIN ST STE 300
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-2728
Practice Address - Country:US
Practice Address - Phone:541-821-9559
Practice Address - Fax:541-702-1236
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional