Basic Information
| Provider Information | |||||||||
| NPI: | 1659716066 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | UPTON | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 517 INDIAN BLUFF ST UNIT 204 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891454576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022743580 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2820 W CHARLESTON BLVD # C23 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891021942 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024374673 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2013 | ||||||||
| LastUpdateDate: | 04/30/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.