Provider Demographics
NPI:1134473721
Name:KNOWLES, BREANNA SUZETTE HALL (BCABA)
Entity Type:Individual
Prefix:MRS
First Name:BREANNA
Middle Name:SUZETTE HALL
Last Name:KNOWLES
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 LYNNHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61571-3323
Mailing Address - Country:US
Mailing Address - Phone:719-688-0218
Mailing Address - Fax:
Practice Address - Street 1:122 LYNNHAVEN DR
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IL
Practice Address - Zip Code:61571-3323
Practice Address - Country:US
Practice Address - Phone:719-688-0218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-04
Last Update Date:2012-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0-12-5194103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst