Healthcare Provider Details

I. General information

NPI: 1508031592
Provider Name (Legal Business Name): ETHAN BREGMAN PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2008
Last Update Date: 02/08/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4746 16TH AVE STE B
SACRAMENTO CA
95820-2925
US

IV. Provider business mailing address

3460 T ST SPT A
SACRAMENTO CA
95816-6654
US

V. Phone/Fax

Practice location:
  • Phone: 916-880-8079
  • Fax:
Mailing address:
  • Phone: 916-880-8079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY21884
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY21884
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3152
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: