Provider Demographics
NPI:1427834472
Name:BRISLIN, KAELEIGH
Entity type:Individual
Prefix:
First Name:KAELEIGH
Middle Name:
Last Name:BRISLIN
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 1:172 HILLCREST AVE
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07506-3046
Mailing Address - Country:US
Mailing Address - Phone:862-290-0537
Mailing Address - Fax:
Practice Address - Street 1:1255 W BASELINE RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-5820
Practice Address - Country:US
Practice Address - Phone:480-820-7675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA021917002251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic