Provider Demographics
NPI:1568894301
Name:VON MIZENER, BRIANA
Entity Type:Individual
Prefix:DR
First Name:BRIANA
Middle Name:
Last Name:VON MIZENER
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 1:1432 E LEE HWY
Mailing Address - Street 2:
Mailing Address - City:LOUDON
Mailing Address - State:TN
Mailing Address - Zip Code:37774-6440
Mailing Address - Country:US
Mailing Address - Phone:865-458-8900
Mailing Address - Fax:865-458-8626
Practice Address - Street 1:1432 E LEE HWY
Practice Address - Street 2:
Practice Address - City:LOUDON
Practice Address - State:TN
Practice Address - Zip Code:37774-6440
Practice Address - Country:US
Practice Address - Phone:865-458-8900
Practice Address - Fax:865-458-8626
Is Sole Proprietor?:No
Enumeration Date:2013-08-03
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2866103TC2200X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ007204Medicaid