Provider Demographics
NPI:1114981099
Name:BRISSON, ANDREA L (DC)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:L
Last Name:BRISSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:
Other - Last Name:GALLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:2302 PACKARD RD
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197
Mailing Address - Country:US
Mailing Address - Phone:734-434-9835
Mailing Address - Fax:734-434-9836
Practice Address - Street 1:2302 PACKARD RD
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197
Practice Address - Country:US
Practice Address - Phone:734-434-9835
Practice Address - Fax:734-434-9836
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-17
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301006167111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI143263159Medicaid
MI143263159Medicaid