Healthcare Provider Details

I. General information

NPI: 1912718370
Provider Name (Legal Business Name): COREY RENEE BRYAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2025
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 E SANTA CLARA ST
SAN JOSE CA
95113-1936
US

IV. Provider business mailing address

425 E SANTA CLARA ST
SAN JOSE CA
95113-1936
US

V. Phone/Fax

Practice location:
  • Phone: 669-245-3428
  • Fax:
Mailing address:
  • Phone: 408-781-9916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: