Provider Demographics
NPI:1548385214
Name:BRISSON, JOHN (PROGRAM COORDINATOR)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BRISSON
Suffix:
Gender:M
Credentials:PROGRAM COORDINATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 N PINE ST
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-3942
Mailing Address - Country:US
Mailing Address - Phone:910-671-5407
Mailing Address - Fax:
Practice Address - Street 1:2300 N PINE ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-3942
Practice Address - Country:US
Practice Address - Phone:910-671-5407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3408280Medicaid