Basic Information
| Provider Information | |||||||||
| NPI: | 1639593551 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOX | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | I | ||||||||
| Credential: | CDP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3800 3RD ST SE | ||||||||
| Address2: | |||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983741109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2536047423 | ||||||||
| FaxNumber: | 2538454742 | ||||||||
| Practice Location | |||||||||
| Address1: | 3800 3RD ST SE | ||||||||
| Address2: | |||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2536047423 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2014 | ||||||||
| LastUpdateDate: | 07/24/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CP60243394 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.