Basic Information
| Provider Information | |||||||||
| NPI: | 1609056472 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRYAN | ||||||||
| FirstName: | DAMON | ||||||||
| MiddleName: | PAUL | ||||||||
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| Credential: | MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2290 E 4500 S STE 180 | ||||||||
| Address2: | |||||||||
| City: | HOLLADAY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841174493 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702592162 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2290 E 4500 S STE 180 | ||||||||
| Address2: | |||||||||
| City: | HOLLADAY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841174493 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704032458 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2007 | ||||||||
| LastUpdateDate: | 11/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.