Healthcare Provider Details

I. General information

NPI: 1568718757
Provider Name (Legal Business Name): BRYAN SANG HYUK NELSON PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2012
Last Update Date: 10/04/2026
Certification Date: 10/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 19961
PORTLAND OR
97280-0961
US

IV. Provider business mailing address

PO BOX 19961
PORTLAND OR
97280-0961
US

V. Phone/Fax

Practice location:
  • Phone: 415-349-0506
  • Fax:
Mailing address:
  • Phone: 612-501-6299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberY835265289516
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number28848
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: