Provider Demographics
NPI:1477673408
Name:GOTTERER, BRIAN JASON (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:JASON
Last Name:GOTTERER
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:P.O. BOX 1794
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92659-0794
Mailing Address - Country:US
Mailing Address - Phone:949-891-1105
Mailing Address - Fax:
Practice Address - Street 1:177 RIVERSIDE AVE STE A, #1794
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-9998
Practice Address - Country:US
Practice Address - Phone:949-891-1105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-31
Last Update Date:2024-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20780103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical