Provider Demographics
NPI:1316475064
Name:BRISBON, NICHOLAS M (MS, PHD)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:M
Last Name:BRISBON
Suffix:
Gender:M
Credentials:MS, PHD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:801 ALBANY ST FL GROUND
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02119
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 BOSTON MEDICAL CTR PL
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118
Practice Address - Country:US
Practice Address - Phone:617-414-5245
Practice Address - Fax:617-414-5520
Is Sole Proprietor?:No
Enumeration Date:2017-05-25
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11231101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health