Provider Demographics
NPI:1417131152
Name:BEZIER, BRIAN R (PHD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:R
Last Name:BEZIER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 S WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-5920
Mailing Address - Country:US
Mailing Address - Phone:920-832-4741
Mailing Address - Fax:920-832-2185
Practice Address - Street 1:410 S WALNUT ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-5920
Practice Address - Country:US
Practice Address - Phone:920-832-4741
Practice Address - Fax:920-832-2185
Is Sole Proprietor?:No
Enumeration Date:2007-12-18
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1972-057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39120900Medicaid
P10577Medicare UPIN