Provider Demographics
NPI:1437851375
Name:PORTWOOD, BREANNA
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:
Last Name:PORTWOOD
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 1:191 JOHN GODLEY LN
Mailing Address - Street 2:
Mailing Address - City:ELLABELL
Mailing Address - State:GA
Mailing Address - Zip Code:31308-8076
Mailing Address - Country:US
Mailing Address - Phone:770-870-0770
Mailing Address - Fax:
Practice Address - Street 1:191 JOHN GODLEY LN
Practice Address - Street 2:
Practice Address - City:ELLABELL
Practice Address - State:GA
Practice Address - Zip Code:31308-8076
Practice Address - Country:US
Practice Address - Phone:770-870-0770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-21
Last Update Date:2025-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician