Healthcare Provider Details

I. General information

NPI: 1437735156
Provider Name (Legal Business Name): BRIAN CRISSMAN CACII
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 03/23/2021
Certification Date: 03/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2112 F ST NW STE 102
WASHINGTON DC
20037-2722
US

IV. Provider business mailing address

11979 HOME GUARD DR
WOODBRIDGE VA
22192-1039
US

V. Phone/Fax

Practice location:
  • Phone: 202-296-4455
  • Fax: 202-822-9130
Mailing address:
  • Phone: 571-330-8033
  • Fax: 202-822-9130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCACII1022
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: