Healthcare Provider Details

I. General information

NPI: 1215744651
Provider Name (Legal Business Name): BRYAN REDDICK DNP, PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2024
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7301 N 16TH ST STE 102
PHOENIX AZ
85020-5266
US

IV. Provider business mailing address

4417 E SAINT CATHERINE AVE
PHOENIX AZ
85042-5363
US

V. Phone/Fax

Practice location:
  • Phone: 623-294-2007
  • Fax:
Mailing address:
  • Phone: 952-221-9581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number316538
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: