Provider Demographics
NPI:1649455635
Name:O'BRYAN, ROBERT ELLIS (MFT)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:ELLIS
Last Name:O'BRYAN
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1915 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SUSANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96130-4519
Mailing Address - Country:US
Mailing Address - Phone:530-257-5900
Mailing Address - Fax:530-257-5901
Practice Address - Street 1:1915 MAIN ST
Practice Address - Street 2:
Practice Address - City:SUSANVILLE
Practice Address - State:CA
Practice Address - Zip Code:96130-4519
Practice Address - Country:US
Practice Address - Phone:530-257-5900
Practice Address - Fax:530-257-5901
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-08
Last Update Date:2010-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 41792106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist