Provider Demographics
NPI:1306986997
Name:BLEW, BRYAN J
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:J
Last Name:BLEW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:MARIPOSA
Mailing Address - State:CA
Mailing Address - Zip Code:95338-0099
Mailing Address - Country:US
Mailing Address - Phone:209-966-7770
Mailing Address - Fax:209-966-8251
Practice Address - Street 1:5037 STROMING RD
Practice Address - Street 2:
Practice Address - City:MARIPOSA
Practice Address - State:CA
Practice Address - Zip Code:95338-0099
Practice Address - Country:US
Practice Address - Phone:209-966-7770
Practice Address - Fax:209-966-8251
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)