Provider Demographics
NPI:1558113431
Name:CLAXTON, BRE'YANA
Entity Type:Individual
Prefix:
First Name:BRE'YANA
Middle Name:
Last Name:CLAXTON
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 1:4040 ASHBY WAY
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-5837
Mailing Address - Country:US
Mailing Address - Phone:313-694-2541
Mailing Address - Fax:
Practice Address - Street 1:4040 ASHBY WAY
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-5837
Practice Address - Country:US
Practice Address - Phone:313-694-2541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA060385587106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician