Provider Demographics
NPI:1619993219
Name:FRITZLER, BRYAN KONRAD (PHD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:KONRAD
Last Name:FRITZLER
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 1:43 WHITING HILL RD STE 300
Mailing Address - Street 2:
Mailing Address - City:BREWER
Mailing Address - State:ME
Mailing Address - Zip Code:04412-1006
Mailing Address - Country:US
Mailing Address - Phone:207-973-4037
Mailing Address - Fax:207-973-8276
Practice Address - Street 1:905 UNION ST
Practice Address - Street 2:SUITE 9
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3050
Practice Address - Country:US
Practice Address - Phone:207-973-4037
Practice Address - Fax:207-973-8276
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS931103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEPS931OtherPSYCHOLOGIST