Provider Demographics
NPI:1558902981
Name:RANTILLA, BRIAR T
Entity Type:Individual
Prefix:
First Name:BRIAR
Middle Name:T
Last Name:RANTILLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4414 NEWTOWN RD APT 4H
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-2253
Mailing Address - Country:US
Mailing Address - Phone:330-979-7672
Mailing Address - Fax:
Practice Address - Street 1:4414 NEWTOWN RD APT 4H
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-2253
Practice Address - Country:US
Practice Address - Phone:330-979-7672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRBT-16-22522106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician