Provider Demographics
NPI:1699077206
Name:MCNUTT, BRYAN R (PHD, LMFT)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:R
Last Name:MCNUTT
Suffix:
Gender:M
Credentials:PHD, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2214 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-2104
Mailing Address - Country:US
Mailing Address - Phone:619-540-6560
Mailing Address - Fax:
Practice Address - Street 1:2214 5TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2104
Practice Address - Country:US
Practice Address - Phone:619-540-6560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-02
Last Update Date:2017-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC52348106H00000X
CAPSY28897103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist