Provider Demographics
NPI:1366712663
Name:STILLER, BRIAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:STILLER
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 1:30MDOS/'SGOHG
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AA
Mailing Address - Zip Code:93437-6307
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1367 E GOSHEN AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2648
Practice Address - Country:US
Practice Address - Phone:903-246-1953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-04
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
TX104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker