Provider Demographics
NPI:1518279751
Name:AMIS, BREYAWNA LA'TECH (BA, MS)
Entity Type:Individual
Prefix:MISS
First Name:BREYAWNA
Middle Name:LA'TECH
Last Name:AMIS
Suffix:
Gender:F
Credentials:BA, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2055 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91103-1324
Mailing Address - Country:US
Mailing Address - Phone:951-532-3276
Mailing Address - Fax:
Practice Address - Street 1:2055 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91103-1324
Practice Address - Country:US
Practice Address - Phone:626-798-6793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-03
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No171M00000XOther Service ProvidersCase Manager/Care Coordinator