Provider Demographics
NPI:1447138094
Name:FREGOSO, BRYAN CESAR
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:CESAR
Last Name:FREGOSO
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 1:393 KIMBERLY DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-3821
Mailing Address - Country:US
Mailing Address - Phone:208-932-5251
Mailing Address - Fax:
Practice Address - Street 1:921 S 8TH AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83209-0001
Practice Address - Country:US
Practice Address - Phone:208-932-5251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-22
Last Update Date:2025-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool