1194870949 NPI number — DR. KELLEY BRYAN GIN PSYD

Table of content: DR. KELLEY BRYAN GIN PSYD (NPI 1194870949)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194870949 NPI number — DR. KELLEY BRYAN GIN PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GIN
Provider First Name:
KELLEY
Provider Middle Name:
BRYAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSYD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194870949
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2711 ALCATRAZ AVE STE 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BERKELEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94705-2726
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-219-7091
Provider Business Mailing Address Fax Number:
510-269-9031

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2711 ALCATRAZ AVE STE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BERKELEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94705-2726
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-219-7091
Provider Business Practice Location Address Fax Number:
510-269-9031
Provider Enumeration Date:
01/24/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  MFC 38529 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X , with the licence number: 20624 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TC0700X , with the licence number: PSY 20624 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)