Healthcare Provider Details

I. General information

NPI: 1629587514
Provider Name (Legal Business Name): BRIAN THOMAS UPTON PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2017
Last Update Date: 09/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6341 PICCADILLY SQUARE DR
MOBILE AL
36609-5103
US

IV. Provider business mailing address

1204 BELLE CHENE DR
MOBILE AL
36693-4511
US

V. Phone/Fax

Practice location:
  • Phone: 251-343-5300
  • Fax:
Mailing address:
  • Phone: 251-490-1982
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2052
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: