Provider Demographics
NPI:1407914773
Name:BRISSETT, MICHAEL JAMES (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAMES
Last Name:BRISSETT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 HILLCREST RD NW
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-1709
Mailing Address - Country:US
Mailing Address - Phone:770-638-1577
Mailing Address - Fax:
Practice Address - Street 1:620 HILLCREST RD NW
Practice Address - Street 2:SUITE 300
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-1709
Practice Address - Country:US
Practice Address - Phone:770-638-1577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000558103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00494205CMedicaid
GA00494205CMedicaid