Provider Demographics
NPI:1689474751
Name:BRAY, BRYAN
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:BRAY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 E LA SALLE ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-2218
Mailing Address - Country:US
Mailing Address - Phone:719-466-4809
Mailing Address - Fax:719-366-8399
Practice Address - Street 1:2976 N ACADEMY BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-5308
Practice Address - Country:US
Practice Address - Phone:719-466-4809
Practice Address - Fax:719-368-8399
Is Sole Proprietor?:No
Enumeration Date:2025-03-17
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician