Provider Demographics
NPI:1437644465
Name:JUSTIN, BRIANNA LARISSA
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:LARISSA
Last Name:JUSTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10856 BLUEBIRD ST NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-4292
Mailing Address - Country:US
Mailing Address - Phone:763-744-7971
Mailing Address - Fax:
Practice Address - Street 1:ST. CLOUD HOSPITAL
Practice Address - Street 2:1406 6TH AVENUE N
Practice Address - City:ST. CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303
Practice Address - Country:US
Practice Address - Phone:320-251-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-22
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10079235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist