Healthcare Provider Details

I. General information

NPI: 1255683199
Provider Name (Legal Business Name): BRYAN FORRESTER PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2012
Last Update Date: 08/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 MOORPARK AVE 300
SAN JOSE CA
95128
US

IV. Provider business mailing address

2400 MOORPARK AVE 300
SAN JOSE CA
95128-2631
US

V. Phone/Fax

Practice location:
  • Phone: 408-975-2730
  • Fax:
Mailing address:
  • Phone: 408-975-2730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY28794
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number28794
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: