Provider Demographics
NPI:1639693211
Name:GIESE GARDNER, BRYAN (LMFT 116141)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:
Last Name:GIESE GARDNER
Suffix:
Gender:M
Credentials:LMFT 116141
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 E CLIFF DR
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-5108
Mailing Address - Country:US
Mailing Address - Phone:831-688-8840
Mailing Address - Fax:
Practice Address - Street 1:519 MAIN ST
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-4356
Practice Address - Country:US
Practice Address - Phone:831-688-8840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-26
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95675101YM0800X, 106H00000X, 101Y00000X
CA116141106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselor