Healthcare Provider Details

I. General information

NPI: 1699077206
Provider Name (Legal Business Name): BRYAN R MCNUTT PH.D, LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2010
Last Update Date: 01/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2214 5TH AVE
SAN DIEGO CA
92101-2104
US

IV. Provider business mailing address

2214 5TH AVE
SAN DIEGO CA
92101-2104
US

V. Phone/Fax

Practice location:
  • Phone: 619-540-6560
  • Fax:
Mailing address:
  • Phone: 619-540-6560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY28897
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC52348
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: