Provider Demographics
NPI:1861616302
Name:BRIESACHER, DEBRA MARIE
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:MARIE
Last Name:BRIESACHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1036 LEFF ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-4444
Mailing Address - Country:US
Mailing Address - Phone:805-785-0967
Mailing Address - Fax:805-783-0262
Practice Address - Street 1:1036 LEFF ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4444
Practice Address - Country:US
Practice Address - Phone:805-785-0967
Practice Address - Fax:805-783-0262
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 37348106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist