Provider Demographics
NPI:1962097956
Name:SLAYNE, BRIAN G (LISAC)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:G
Last Name:SLAYNE
Suffix:
Gender:M
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1745 E GLENN ST APT 138
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-2739
Mailing Address - Country:US
Mailing Address - Phone:520-912-1714
Mailing Address - Fax:
Practice Address - Street 1:5151 E PIMA ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-3627
Practice Address - Country:US
Practice Address - Phone:520-477-0227
Practice Address - Fax:602-325-2083
Is Sole Proprietor?:No
Enumeration Date:2021-03-02
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-15201101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)