Provider Demographics
NPI:1730934316
Name:BRISTER, MICHAEL (AA, CPC, SUDPT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BRISTER
Suffix:
Gender:M
Credentials:AA, CPC, SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5005 PACIFIC HWY E STE 20
Mailing Address - Street 2:
Mailing Address - City:FIFE
Mailing Address - State:WA
Mailing Address - Zip Code:98424-2647
Mailing Address - Country:US
Mailing Address - Phone:253-922-9522
Mailing Address - Fax:253-922-6955
Practice Address - Street 1:5005 PACIFIC HWY E STE 20
Practice Address - Street 2:
Practice Address - City:FIFE
Practice Address - State:WA
Practice Address - Zip Code:98424-2647
Practice Address - Country:US
Practice Address - Phone:253-922-9522
Practice Address - Fax:253-922-6955
Is Sole Proprietor?:No
Enumeration Date:2024-04-18
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61442091101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)