Provider Demographics
NPI:1184788754
Name:BRISENO, JUDY (LPT)
Entity type:Individual
Prefix:MRS
First Name:JUDY
Middle Name:
Last Name:BRISENO
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5063 MIDWAY RD
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-9697
Mailing Address - Country:US
Mailing Address - Phone:707-678-5614
Mailing Address - Fax:707-678-4690
Practice Address - Street 1:161 VALHALLA CT
Practice Address - Street 2:5063 MIDWAY RD
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687-6225
Practice Address - Country:US
Practice Address - Phone:707-678-5614
Practice Address - Fax:707-678-4690
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT22322167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician