Provider Demographics
NPI:1396783205
Name:VETTE, BRYANT
Entity type:Individual
Prefix:
First Name:BRYANT
Middle Name:
Last Name:VETTE
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 1:20036 BADGER RD
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-2570
Mailing Address - Country:US
Mailing Address - Phone:541-200-0603
Mailing Address - Fax:
Practice Address - Street 1:20036 BADGER RD
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-2570
Practice Address - Country:US
Practice Address - Phone:541-200-0603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009409103TC0700X
MI68010743891041C0700X
ORL61411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2015165OtherCIGNA #
MIOF16408025Medicare PIN