Provider Demographics
NPI:1790366300
Name:BUMPHUS, BRIAN (PRSS)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:BUMPHUS
Suffix:
Gender:M
Credentials:PRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 AUSTIN HWY
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-4337
Mailing Address - Country:US
Mailing Address - Phone:210-753-1130
Mailing Address - Fax:
Practice Address - Street 1:26229 N CRANES MILL RD
Practice Address - Street 2:
Practice Address - City:CANYON LAKE
Practice Address - State:TX
Practice Address - Zip Code:78133-1957
Practice Address - Country:US
Practice Address - Phone:930-935-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-15
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX41704171101YA0400X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)