Provider Demographics
NPI:1396950556
Name:BRISBANE, GLENDA (MS)
Entity type:Individual
Prefix:MS
First Name:GLENDA
Middle Name:
Last Name:BRISBANE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2012 HUNTINGTON DR
Mailing Address - Street 2:#6
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-4944
Mailing Address - Country:US
Mailing Address - Phone:323-226-5073
Mailing Address - Fax:323-226-4417
Practice Address - Street 1:LACUSC MEDICAL CENTER
Practice Address - Street 2:2010 ZONAL AVE OPD ROOM 2P70
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033
Practice Address - Country:US
Practice Address - Phone:323-226-5073
Practice Address - Fax:323-226-4417
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU1136231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAU1136OtherAUDIOLOGY