Provider Demographics
NPI:1720711831
Name:MIDYETT, BRIANA NICOLE
Entity Type:Individual
Prefix:
First Name:BRIANA
Middle Name:NICOLE
Last Name:MIDYETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRIANA
Other - Middle Name:NICOLE
Other - Last Name:FRECH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4921 INDIAN WOOD RD UNIT 388
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-8524
Mailing Address - Country:US
Mailing Address - Phone:707-293-0197
Mailing Address - Fax:
Practice Address - Street 1:5105 W GOLDLEAF CIR
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90056-1269
Practice Address - Country:US
Practice Address - Phone:323-298-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102209104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker