Healthcare Provider Details

I. General information

NPI: 1194006916
Provider Name (Legal Business Name): DEBORAH RACHELL BRYANT L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2011
Last Update Date: 09/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18880 CHERRY VALLEY BLVD
TUOLUMNE CA
95379-9506
US

IV. Provider business mailing address

PO BOX 3322
SONORA CA
95370-3322
US

V. Phone/Fax

Practice location:
  • Phone: 209-928-5400
  • Fax: 209-928-5412
Mailing address:
  • Phone: 209-533-4589
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS26623
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number421925
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number421925
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: