Provider Demographics
NPI:1093433310
Name:SEREAL, BRESHONA BREANA (RBT)
Entity Type:Individual
Prefix:
First Name:BRESHONA
Middle Name:BREANA
Last Name:SEREAL
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6737 BILL CARRUTH PKWY APT 5223
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-3782
Mailing Address - Country:US
Mailing Address - Phone:678-767-7475
Mailing Address - Fax:
Practice Address - Street 1:296 MERCHANTS SQ
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30132-5029
Practice Address - Country:US
Practice Address - Phone:470-391-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-22-212614106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician