Provider Demographics
NPI:1407578487
Name:BRISTER, LODEANA RAYLEE
Entity Type:Individual
Prefix:
First Name:LODEANA
Middle Name:RAYLEE
Last Name:BRISTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LODEANA
Other - Middle Name:RAYLEE
Other - Last Name:BRISTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4235 CEDAR SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-2691
Mailing Address - Country:US
Mailing Address - Phone:405-882-1758
Mailing Address - Fax:
Practice Address - Street 1:4235 CEDAR SPRINGS RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-2691
Practice Address - Country:US
Practice Address - Phone:405-882-1758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-15
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician