Provider Demographics
NPI:1629587514
Name:UPTON, BRIAN THOMAS (PHD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:THOMAS
Last Name:UPTON
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 1:1204 BELLE CHENE DR
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36693-4511
Mailing Address - Country:US
Mailing Address - Phone:251-490-1982
Mailing Address - Fax:
Practice Address - Street 1:6341 PICCADILLY SQUARE DR
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36609-5103
Practice Address - Country:US
Practice Address - Phone:251-343-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-24
Last Update Date:2017-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2052103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty