Provider Demographics
NPI:1316100175
Name:BRYAN, LUPE E
Entity type:Individual
Prefix:MRS
First Name:LUPE
Middle Name:E
Last Name:BRYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1043 HWY 313
Mailing Address - Street 2:
Mailing Address - City:BERNALILLO
Mailing Address - State:NM
Mailing Address - Zip Code:87004-6912
Mailing Address - Country:US
Mailing Address - Phone:505-867-3351
Mailing Address - Fax:505-867-3514
Practice Address - Street 1:1043 HWY 313
Practice Address - Street 2:
Practice Address - City:BERNALILLO
Practice Address - State:NM
Practice Address - Zip Code:87004-6912
Practice Address - Country:US
Practice Address - Phone:505-867-3351
Practice Address - Fax:505-867-3514
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM67352101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)