Healthcare Provider Details

I. General information

NPI: 1689599136
Provider Name (Legal Business Name): BRYCE WHITESIDE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5082 OLD HWY N
MARIPOSA CA
95338-2430
US

IV. Provider business mailing address

1101 GETTYSBURG AVE APT 2229
CLOVIS CA
93612-3976
US

V. Phone/Fax

Practice location:
  • Phone: 209-742-0250
  • Fax: 209-966-4549
Mailing address:
  • Phone: 559-909-4522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number260182905
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: