Provider Demographics
NPI:1982868378
Name:BAUCOM, BRIAN ROBERT (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:ROBERT
Last Name:BAUCOM
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 1:6310 SAN VICENTE BLVD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5426
Mailing Address - Country:US
Mailing Address - Phone:310-625-9267
Mailing Address - Fax:
Practice Address - Street 1:6310 SAN VICENTE BLVD
Practice Address - Street 2:SUITE 350
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5426
Practice Address - Country:US
Practice Address - Phone:310-625-9267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-15
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSB 33264103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist