Provider Demographics
NPI:1437853702
Name:BRISSE, NICOLE RENEE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENEE
Last Name:BRISSE
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 1:6540 PARK VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48348-4552
Mailing Address - Country:US
Mailing Address - Phone:248-303-3030
Mailing Address - Fax:
Practice Address - Street 1:505 E MAPLE RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-2806
Practice Address - Country:US
Practice Address - Phone:248-918-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-29
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI171M00000X106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician