Provider Demographics
NPI:1164186235
Name:BLOCKER, BREANNA
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:
Last Name:BLOCKER
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 1:18 ABBOT ST APT 2
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-1691
Mailing Address - Country:US
Mailing Address - Phone:978-457-2594
Mailing Address - Fax:
Practice Address - Street 1:18 ABBOT ST APT 2
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02124-1691
Practice Address - Country:US
Practice Address - Phone:978-457-2594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-26
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician