1366147563 NPI number — AMBER MARIE BRYAN

Table of content: AMBER MARIE BRYAN (NPI 1366147563)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366147563 NPI number — AMBER MARIE BRYAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRYAN
Provider First Name:
AMBER
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1366147563
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/03/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
134 MAEGAN PL APT 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
THOUSAND OAKS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91362-2763
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-232-2557
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5250 RALSTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VENTURA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93003-7318
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-714-2557
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/05/2023

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: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0009925102 . This is a "LICENSED SOCIAL WORKER" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 9134 . This is a "LICENSED MASTER SOCIAL WORKER" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: ASW118914 . This is a "ASSOCIATE CLINICAL SOCIAL WORKER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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