Provider Demographics
NPI:1013155753
Name:BRISCO, KIMBERLY ANDREA
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANDREA
Last Name:BRISCO
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 1:645 E 120TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90059-2721
Mailing Address - Country:US
Mailing Address - Phone:323-779-6707
Mailing Address - Fax:
Practice Address - Street 1:5436 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037-4126
Practice Address - Country:US
Practice Address - Phone:323-234-6261
Practice Address - Fax:323-234-6265
Is Sole Proprietor?:No
Enumeration Date:2009-02-03
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
195709AOtherMEDICAL