Provider Demographics
NPI:1104539626
Name:SPYRISON, BRUCE RONALD (SUDPT)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:RONALD
Last Name:SPYRISON
Suffix:
Gender:M
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1206 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98363-5620
Mailing Address - Country:US
Mailing Address - Phone:360-809-8081
Mailing Address - Fax:
Practice Address - Street 1:825 E 5TH ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-3818
Practice Address - Country:US
Practice Address - Phone:360-477-4795
Practice Address - Fax:360-477-4798
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-29
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61385536101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)