Provider Demographics
NPI:1689824518
Name:BOVITZ, BRYAN W (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:W
Last Name:BOVITZ
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 1:208 CASABLANCA AVE.
Mailing Address - Street 2:27 SGOMH
Mailing Address - City:CANNON AFB
Mailing Address - State:NM
Mailing Address - Zip Code:88101-5014
Mailing Address - Country:US
Mailing Address - Phone:575-784-1108
Mailing Address - Fax:575-784-4624
Practice Address - Street 1:208 CASABLANCA AVE.
Practice Address - Street 2:27 SGOMH
Practice Address - City:CANNON AFB
Practice Address - State:NM
Practice Address - Zip Code:88101-5014
Practice Address - Country:US
Practice Address - Phone:575-784-1108
Practice Address - Fax:575-784-4624
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-29
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00003930103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical