Provider Demographics
NPI:1669947792
Name:ROMAN, BRENTON (PSYD)
Entity type:Individual
Prefix:
First Name:BRENTON
Middle Name:
Last Name:ROMAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6161 EL CAJON BLVD STE B509
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-3922
Mailing Address - Country:US
Mailing Address - Phone:203-513-1208
Mailing Address - Fax:
Practice Address - Street 1:865 3RD AVE
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-1300
Practice Address - Country:US
Practice Address - Phone:619-409-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-04
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY30333103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical