Provider Demographics
NPI:1235862640
Name:KENDRICKS, BRESHONDRA DIAHANNA (BA)
Entity Type:Individual
Prefix:
First Name:BRESHONDRA
Middle Name:DIAHANNA
Last Name:KENDRICKS
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4920 ROSWELL RD STE 1
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-2684
Mailing Address - Country:US
Mailing Address - Phone:470-258-4050
Mailing Address - Fax:
Practice Address - Street 1:4920 ROSWELL RD STE 1
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-2684
Practice Address - Country:US
Practice Address - Phone:470-258-4050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-04
Last Update Date:2022-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician