Provider Demographics
NPI:1902336498
Name:ANDERSON, BRYAN GEOFFREY
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:GEOFFREY
Last Name:ANDERSON
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 1:2300 WESTRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-1229
Mailing Address - Country:US
Mailing Address - Phone:310-562-5258
Mailing Address - Fax:
Practice Address - Street 1:1247 7TH ST STE 202
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-1643
Practice Address - Country:US
Practice Address - Phone:310-562-5258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA758211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical