Provider Demographics
NPI:1053410878
Name:BRISON-MOLL, NANCY LYNN (PHD)
Entity type:Individual
Prefix:DR
First Name:NANCY
Middle Name:LYNN
Last Name:BRISON-MOLL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:965 E YOSEMITE AVE STE 12
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-5944
Mailing Address - Country:US
Mailing Address - Phone:209-483-4498
Mailing Address - Fax:209-824-0010
Practice Address - Street 1:965 E YOSEMITE AVE STE 12
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-5944
Practice Address - Country:US
Practice Address - Phone:209-483-4498
Practice Address - Fax:209-824-0010
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 15243103TC0700X
CAPSY15243103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5088836Medicaid