Provider Demographics
NPI:1043840192
Name:TIA BRISCO, LICENSED MARRIAGE AND FAMILY THERAPY, INC.
Entity type:Organization
Organization Name:TIA BRISCO, LICENSED MARRIAGE AND FAMILY THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRISCO
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:661-675-8756
Mailing Address - Street 1:17130 DEVONSHIRE ST STE 104A
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-1676
Mailing Address - Country:US
Mailing Address - Phone:661-675-8756
Mailing Address - Fax:
Practice Address - Street 1:17130 DEVONSHIRE ST STE 104A
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-1676
Practice Address - Country:US
Practice Address - Phone:661-675-8756
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-16
Last Update Date:2020-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health