Healthcare Provider Details

I. General information

NPI: 1720334535
Provider Name (Legal Business Name): BRIAN BUZZELLA PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2012
Last Update Date: 10/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4025 CAMINO DEL RIO S STE 300
SAN DIEGO CA
92108-4108
US

IV. Provider business mailing address

4025 CAMINO DEL RIO S STE 300
SAN DIEGO CA
92108-4108
US

V. Phone/Fax

Practice location:
  • Phone: 619-542-7745
  • Fax:
Mailing address:
  • Phone: 619-542-7745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number25059
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: