Provider Demographics
NPI:1447969100
Name:DORIA, BRYCE XAVIER AGUSTIN (HS)
Entity type:Individual
Prefix:
First Name:BRYCE XAVIER
Middle Name:AGUSTIN
Last Name:DORIA
Suffix:
Gender:M
Credentials:HS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1462 EDGEHILL DR
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-2982
Mailing Address - Country:US
Mailing Address - Phone:619-306-5577
Mailing Address - Fax:
Practice Address - Street 1:3550 CAMINO DEL RIO N STE 104
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-1738
Practice Address - Country:US
Practice Address - Phone:760-815-9536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-21
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician