Provider Demographics
NPI:1053042580
Name:BREVARD, ARION IMANI
Entity Type:Individual
Prefix:
First Name:ARION
Middle Name:IMANI
Last Name:BREVARD
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 1:105 GRAND CENTRAL BLVD
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-4148
Mailing Address - Country:US
Mailing Address - Phone:912-446-2473
Mailing Address - Fax:
Practice Address - Street 1:105 GRAND CENTRAL BLVD
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-4148
Practice Address - Country:US
Practice Address - Phone:912-446-2473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-24
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA22-221229106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician