Basic Information
| Provider Information | |||||||||
| NPI: | 1770663460 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRISMAN | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 675 TOWER AVE | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061121273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607142750 | ||||||||
| FaxNumber: | 8607148591 | ||||||||
| Practice Location | |||||||||
| Address1: | 675 TOWER AVE | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061121273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607142750 | ||||||||
| FaxNumber: | 8607148591 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 03/15/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 002344 | CT | N | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | 002344 | CT | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.