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NPI Code Detail

MEDICARE: BRYAN WAYNE ANDERSON NCC

MEDICARE: BRYAN WAYNE ANDERSON NCC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YM0800XMental Health Counselor

General Provider Information

NPI Number : 1861161432
Entity Type Code : Individual
Provider Name (Legal Business Name) : BRYAN WAYNE ANDERSON NCC
Provider Business Mailing Address
First Line : 151 N 3RD AVE STE 330
Second Line :
City : POCATELLO
State : ID
Zip : 83201-6369
Country : US
Telephone Number : 208-242-3771
Fax Number :
Provider Business Practice Location Address
First Line : 151 N 3RD AVE STE 330
Second Line :
City : POCATELLO
State : ID
Zip : 83201-6369
Country : US
Telephone Number : 208-242-3771
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/08/2021
Last Update Date : 09/08/2021

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Directions to “ BRYAN WAYNE ANDERSON NCC” Practice Location

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