Provider Demographics
NPI:1003687914
Name:ECONOMOS, BREANNA MARIE
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:MARIE
Last Name:ECONOMOS
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 1:2290 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-6277
Mailing Address - Country:US
Mailing Address - Phone:631-708-6257
Mailing Address - Fax:
Practice Address - Street 1:2290 9TH AVE
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-6277
Practice Address - Country:US
Practice Address - Phone:631-708-6257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP126356106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist