Healthcare Provider Details

I. General information

NPI: 1811809726
Provider Name (Legal Business Name): BRYAN ACOSTA MS, LIAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17242 S HEALTHCARE DR
LAVEEN AZ
85339-8501
US

IV. Provider business mailing address

11367 W OVERLIN DR
AVONDALE AZ
85323-1131
US

V. Phone/Fax

Practice location:
  • Phone: 520-796-3815
  • Fax:
Mailing address:
  • Phone: 602-465-9831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLIAC-155408
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: