Provider Demographics
NPI:1184851206
Name:NISSEN, BRIAN EDWARD (LBSW)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:EDWARD
Last Name:NISSEN
Suffix:
Gender:M
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 N MAIN STREET BOX 74
Mailing Address - Street 2:
Mailing Address - City:HAZELTON
Mailing Address - State:IA
Mailing Address - Zip Code:50641-7701
Mailing Address - Country:US
Mailing Address - Phone:319-636-2100
Mailing Address - Fax:319-636-2022
Practice Address - Street 1:105 N MAIN STREET BOX 74
Practice Address - Street 2:
Practice Address - City:HAZELTON
Practice Address - State:IA
Practice Address - Zip Code:50641-7701
Practice Address - Country:US
Practice Address - Phone:319-636-2100
Practice Address - Fax:319-636-2022
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health