Provider Demographics
NPI:1700541398
Name:RISNER, BRANDON MICHAEL (CDCA)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:MICHAEL
Last Name:RISNER
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 JUNE ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-3417
Mailing Address - Country:US
Mailing Address - Phone:567-280-4531
Mailing Address - Fax:567-208-4574
Practice Address - Street 1:825 JUNE ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-3417
Practice Address - Country:US
Practice Address - Phone:567-280-4531
Practice Address - Fax:567-208-4574
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-08
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.178812101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)