Provider Demographics
NPI:1346959855
Name:BRISSETTE, STEPHANIE ANN (AMFT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:BRISSETTE
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:ANN
Other - Last Name:TALLMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AMFT
Mailing Address - Street 1:4141 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-3215
Mailing Address - Country:US
Mailing Address - Phone:715-614-2380
Mailing Address - Fax:
Practice Address - Street 1:4141 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-3215
Practice Address - Country:US
Practice Address - Phone:715-614-2380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-23
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT132879106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist