Provider Demographics
NPI:1740346535
Name:BRISLIN, PHILIP N (LCSW)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:N
Last Name:BRISLIN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 S PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18701-3301
Mailing Address - Country:US
Mailing Address - Phone:570-552-6148
Mailing Address - Fax:570-552-6021
Practice Address - Street 1:110 S PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18701-3301
Practice Address - Country:US
Practice Address - Phone:570-552-6148
Practice Address - Fax:570-552-6021
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW000909L1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA279023OtherVALUEOPTIONS
PA195013OtherMHN
PA534876Medicare UPIN
PA068903Medicare PIN