Healthcare Provider Details

I. General information

NPI: 1831346170
Provider Name (Legal Business Name): BRYAN B BUSHMAN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2008
Last Update Date: 12/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5030 HARRISON BLVD
OGDEN UT
84403-4311
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-387-5600
  • Fax:
Mailing address:
  • Phone: 801-387-5600
  • Fax: 801-475-1621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number5842642-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: