Healthcare Provider Details

I. General information

NPI: 1689784688
Provider Name (Legal Business Name): BRYAN D NESTRIPKE PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 08/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

913 NW GARDEN VALLEY BLVD
ROSEBURG OR
97471-6523
US

IV. Provider business mailing address

2041 OAK HILL RD
ROSEBURG OR
97471-9657
US

V. Phone/Fax

Practice location:
  • Phone: 541-440-1000
  • Fax:
Mailing address:
  • Phone: 435-841-0018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1302820-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: