Healthcare Provider Details

I. General information

NPI: 1225964349
Provider Name (Legal Business Name): BRIANNA L VESTAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7864 MOORSBRIDGE RD
PORTAGE MI
49024-4424
US

IV. Provider business mailing address

31322 COUNTY ROAD 390 APT A
GOBLES MI
49055-9324
US

V. Phone/Fax

Practice location:
  • Phone: 313-278-4601
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7152001420
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: