Provider Demographics
NPI:1518038736
Name:RICH, BRYAN W (PHD, LMFT)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:W
Last Name:RICH
Suffix:
Gender:M
Credentials:PHD, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 EMELINE AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-1976
Mailing Address - Country:US
Mailing Address - Phone:831-454-7503
Mailing Address - Fax:
Practice Address - Street 1:1400 EMELINE AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-1976
Practice Address - Country:US
Practice Address - Phone:831-454-7503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 40827106H00000X
CAPSY27355103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC70044FOtherMEDI-CAL PTAN GROUP#
CAZZZ91891ZOtherSANTA CRUZ COUNTY MEDICARE GROUP PTAN#
CAFHC70042FOtherMEDI-CAL PTAN GROUP#
CAZZZ92069ZOtherSANTA CRUZ COUNTY MEDICARE GROUP PTAN#
CAZZZ91892ZOtherSANTA CRUZ COUNTY MEDICARE GROUP PTAN#