Provider Demographics
NPI:1639593551
Name:BOX, BRYAN LEE I (CDP)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:LEE
Last Name:BOX
Suffix:I
Gender:M
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 3RD ST SE
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-1109
Mailing Address - Country:US
Mailing Address - Phone:253-604-7423
Mailing Address - Fax:253-845-4742
Practice Address - Street 1:3800 3RD ST SE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374
Practice Address - Country:US
Practice Address - Phone:253-604-7423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-12
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60243394101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)