Provider Demographics
NPI:1780321679
Name:KREISMAN, BRIAN MATTHEW (PHD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:MATTHEW
Last Name:KREISMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2848 BELLEGLADE CT SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8011
Mailing Address - Country:US
Mailing Address - Phone:616-914-2020
Mailing Address - Fax:
Practice Address - Street 1:2907 BRETON RD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512-1745
Practice Address - Country:US
Practice Address - Phone:616-914-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-12
Last Update Date:2023-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000622231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1601000622OtherSTATE OF MICHIGAN AUDIOLOGY LICENSE