Provider Demographics
NPI:1720469422
Name:BRISENO, MELISSA (LCDC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:BRISENO
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 E CRESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-3309
Mailing Address - Country:US
Mailing Address - Phone:361-576-4673
Mailing Address - Fax:361-576-6557
Practice Address - Street 1:802 E CRESTWOOD DR
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-3309
Practice Address - Country:US
Practice Address - Phone:361-576-4673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-18
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12370101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX12370OtherTEXAS DEPARTMENT OF STATE AND HEALTH SERVICES