Provider Demographics
NPI:1356127096
Name:DE JUSTIN, BRYAN
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:DE JUSTIN
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 1:2704 MEDINAH WAY
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-9619
Mailing Address - Country:US
Mailing Address - Phone:408-888-4587
Mailing Address - Fax:
Practice Address - Street 1:1235 MCHENRY AVE
Practice Address - Street 2:SUITE #A & #B
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350
Practice Address - Country:US
Practice Address - Phone:209-527-4597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)