Provider Demographics
NPI:1518212190
Name:BRIGHAM, KOREN PHILENE (MA)
Entity Type:Individual
Prefix:
First Name:KOREN
Middle Name:PHILENE
Last Name:BRIGHAM
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 PROSPECT PL
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-2801
Mailing Address - Country:US
Mailing Address - Phone:917-855-3908
Mailing Address - Fax:
Practice Address - Street 1:31 PROSPECT PL
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217-2801
Practice Address - Country:US
Practice Address - Phone:917-855-3908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-19
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY632812121174400000X
NY632817121174400000X
NY632816121174400000X
NY632811121174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist