Healthcare Provider Details

I. General information

NPI: 1760636724
Provider Name (Legal Business Name): MELISSA LAUREN BRISBANE L.I.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2008
Last Update Date: 01/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 PENNSYLVANIA AVE SE SUITE 242
WASHINGTON DC
20003-4318
US

IV. Provider business mailing address

814 5TH ST NE APT 1
WASHINGTON DC
20002-4322
US

V. Phone/Fax

Practice location:
  • Phone: 202-550-6406
  • Fax:
Mailing address:
  • Phone: 202-550-6406
  • Fax: 202-318-1289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC50078615
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: