Provider Demographics
NPI:1467036137
Name:BALVANEDA, BRYAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:
Last Name:BALVANEDA
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 1:200 W. ARBOR DRIVE
Mailing Address - Street 2:MC# 0304
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103
Mailing Address - Country:US
Mailing Address - Phone:858-534-2628
Mailing Address - Fax:
Practice Address - Street 1:200 W. ARBOR DRIVE
Practice Address - Street 2:MC# 0304
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103
Practice Address - Country:US
Practice Address - Phone:858-534-2628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-10
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33774103TC0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical