Provider Demographics
NPI:1386069276
Name:BRYANT, PRESTON
Entity type:Individual
Prefix:
First Name:PRESTON
Middle Name:
Last Name:BRYANT
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 1:640 N SAN JACINTO ST STE A
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-3188
Mailing Address - Country:US
Mailing Address - Phone:951-658-2299
Mailing Address - Fax:
Practice Address - Street 1:640 N SAN JACINTO ST STE A
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-3188
Practice Address - Country:US
Practice Address - Phone:951-658-2299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-28
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARI-B0909150949101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)