Healthcare Provider Details

I. General information

NPI: 1750121778
Provider Name (Legal Business Name): BRYAN LOUIS BIXBY DEAN SUDCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2024
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 PETER BEHR DR
SAN RAFAEL CA
94903-5216
US

IV. Provider business mailing address

21 CARLSON CT
SAN ANSELMO CA
94960-1354
US

V. Phone/Fax

Practice location:
  • Phone: 415-473-4119
  • Fax:
Mailing address:
  • Phone: 415-902-6825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: