Provider Demographics
NPI:1932488921
Name:BRYAN, DIANE HARDWICK (MPS, PHD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:HARDWICK
Last Name:BRYAN
Suffix:
Gender:F
Credentials:MPS, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 GOMEZ RD
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79932-4205
Mailing Address - Country:US
Mailing Address - Phone:915-585-3884
Mailing Address - Fax:915-581-6708
Practice Address - Street 1:851 GOMEZ RD
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79932-4205
Practice Address - Country:US
Practice Address - Phone:915-585-3884
Practice Address - Fax:915-581-6708
Is Sole Proprietor?:No
Enumeration Date:2011-08-09
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX62311101YP2500X
TX7697101YA0400X
NM3432101YA0400X
NM0039101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM14324059Medicaid