Provider Demographics
NPI:1407958655
Name:BRISSEY, DIANE SMITH (LCSWC)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:SMITH
Last Name:BRISSEY
Suffix:
Gender:F
Credentials:LCSWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 N MAIN ST
Mailing Address - Street 2:P.O. BOX 925
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-1060
Mailing Address - Country:US
Mailing Address - Phone:410-641-4598
Mailing Address - Fax:
Practice Address - Street 1:124 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-1060
Practice Address - Country:US
Practice Address - Phone:410-641-4598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2010-06-10
Deactivation Date:2010-05-26
Deactivation Code:
Reactivation Date:2010-06-10
Provider Licenses
StateLicense IDTaxonomies
MD082891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD222731200Medicaid