Provider Demographics
NPI:1407402308
Name:LEE, BREANNA (BCBA/COBA)
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:BCBA/COBA
Other - Prefix:
Other - First Name:BREANNA
Other - Middle Name:
Other - Last Name:BURNS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2522 NUTTER PARK DR
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45434-3500
Mailing Address - Country:US
Mailing Address - Phone:937-306-8811
Mailing Address - Fax:
Practice Address - Street 1:2522 NUTTER PARK DR
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45434-3500
Practice Address - Country:US
Practice Address - Phone:937-306-8811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-15
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
COBA.00620103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1473276Medicaid