Provider Demographics
NPI:1417689795
Name:FIALA, BREANNA (MA, LLC)
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:
Last Name:FIALA
Suffix:
Gender:F
Credentials:MA, LLC
Other - Prefix:
Other - First Name:BREANNA
Other - Middle Name:
Other - Last Name:ROOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1750 GRAND RIDGE CT NE STE 200
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-7043
Mailing Address - Country:US
Mailing Address - Phone:616-426-9034
Mailing Address - Fax:
Practice Address - Street 1:1750 GRAND RIDGE CT NE STE 200
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-7043
Practice Address - Country:US
Practice Address - Phone:616-426-9034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-27
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451022226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health