Basic Information
| Provider Information | |||||||||
| NPI: | 1154634541 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRISENO | ||||||||
| FirstName: | VANESSA | ||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FLORES | ||||||||
| OtherFirstName: | VANESSA | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1085 W VICTORIA ST | ||||||||
| Address2: | |||||||||
| City: | COMPTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902205804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108685379 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1501 HUGHES WAY STE 150 | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3102216336 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2010 | ||||||||
| LastUpdateDate: | 03/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | AMFT117768 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.