Healthcare Provider Details

I. General information

NPI: 1255813176
Provider Name (Legal Business Name): BRIAN ALLEN MFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2018
Last Update Date: 09/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 GLASSON WAY
GRASS VALLEY CA
95945-5723
US

IV. Provider business mailing address

12478 HILLCREST DR
NEVADA CITY CA
95959-8967
US

V. Phone/Fax

Practice location:
  • Phone: 530-470-2409
  • Fax:
Mailing address:
  • Phone: 510-725-7766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: