Provider Demographics
NPI:1114636701
Name:GILLIS, BREANNE N
Entity Type:Individual
Prefix:
First Name:BREANNE
Middle Name:N
Last Name:GILLIS
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 1:6401 PARK ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33024-4122
Mailing Address - Country:US
Mailing Address - Phone:754-204-2736
Mailing Address - Fax:
Practice Address - Street 1:5400 S UNIVERSITY DR STE 502
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-5313
Practice Address - Country:US
Practice Address - Phone:888-875-4039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-22
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty