=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053266718
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRYON EVAN JOHNSON CPRSS-S
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2026
-----------------------------------------------------
Last Update Date | 02/27/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3852 PALOS VERDES ST
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89119-6909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-831-9878
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2675 HEATHROW ST
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89135-2604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-831-9878
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 175T00000X
-----------------------------------------------------
Taxonomy Name | Peer Specialist
-----------------------------------------------------
License Number | PRSS-SUP-5173
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------