Provider Demographics
NPI:1205595113
Name:CRISP, BREANNA NICOLE (LCSW)
Entity type:Individual
Prefix:MISS
First Name:BREANNA
Middle Name:NICOLE
Last Name:CRISP
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 N CASWELL RD # 303
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-2442
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:360 N CASWELL RD # 303
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2442
Practice Address - Country:US
Practice Address - Phone:704-981-2676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0143351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical