Basic Information
| Provider Information | |||||||||
| NPI: | 1043556624 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MURRAY | ||||||||
| FirstName: | BRITTNEY | ||||||||
| MiddleName: | TATTERSALL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRISTOW-MURRAY | ||||||||
| OtherFirstName: | BRITTNEY | ||||||||
| OtherMiddleName: | TATTERSALL | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 303 N CLYDE MORRIS BLVD | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321142709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142195000 | ||||||||
| FaxNumber: | 4142195422 | ||||||||
| Practice Location | |||||||||
| Address1: | 1020 N 12TH ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532331308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142195000 | ||||||||
| FaxNumber: | 4142195422 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2012 | ||||||||
| LastUpdateDate: | 10/05/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | PY10811 | FL | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 6150 | WI | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 180.009964 | IL | N | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.