Provider Demographics
NPI:1174216816
Name:BRISTER, MICHELLE DENISE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DENISE
Last Name:BRISTER
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 1:12783 CEDAR RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44106-3359
Mailing Address - Country:US
Mailing Address - Phone:216-278-6757
Mailing Address - Fax:
Practice Address - Street 1:14100 LAKE SHORE BLVD APT 304
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44110-1941
Practice Address - Country:US
Practice Address - Phone:216-278-6757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-30
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1174216816171M00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator