Provider Demographics
NPI:1689315111
Name:BRYAN, CHARLES DOUGLAS
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:DOUGLAS
Last Name:BRYAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 HOSPITAL WAY STE 422
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2744
Mailing Address - Country:US
Mailing Address - Phone:208-557-9450
Mailing Address - Fax:208-561-7111
Practice Address - Street 1:373 W HIGHWAY 39 STE 1
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-5228
Practice Address - Country:US
Practice Address - Phone:208-557-9450
Practice Address - Fax:208-561-7111
Is Sole Proprietor?:No
Enumeration Date:2022-04-06
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-278721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical