Provider Demographics
NPI:1770510653
Name:BRIZENDINE, RONALD MITCHELL (LCSW)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:MITCHELL
Last Name:BRIZENDINE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629 TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620
Mailing Address - Country:US
Mailing Address - Phone:423-968-2225
Mailing Address - Fax:423-968-2225
Practice Address - Street 1:#6 SIXTH STREET SUITE 205
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620
Practice Address - Country:US
Practice Address - Phone:423-968-2225
Practice Address - Fax:423-968-2225
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00005951041C0700X
VA09040029721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
099441OtherBCBS OF VA
VA8906416Medicaid
TN3690473Medicare ID - Type Unspecified