Provider Demographics
NPI:1134260003
Name:RISSER, BRIAN (MPT)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:RISSER
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 MAGNOLIA BAYOU BLVD
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-1203
Mailing Address - Country:US
Mailing Address - Phone:251-689-6387
Mailing Address - Fax:251-679-0091
Practice Address - Street 1:205 SARALAND BLVD N
Practice Address - Street 2:
Practice Address - City:SARALAND
Practice Address - State:AL
Practice Address - Zip Code:36571-2126
Practice Address - Country:US
Practice Address - Phone:251-679-0015
Practice Address - Fax:251-679-0091
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH4963225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist