Provider Demographics
NPI:1720568736
Name:BRAUN, RYAN KELLEY
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:KELLEY
Last Name:BRAUN
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 1:3948 1/2 MISSISSIPPI ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-2733
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4309 3RD AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-1407
Practice Address - Country:US
Practice Address - Phone:619-876-4502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-19
Last Update Date:2018-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
775602719OtherTUFT HEALTH FREEDOM PLAN