Provider Demographics
NPI:1689259145
Name:DAVIS-BLOOM, BREANNAH KATRICE (BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:BREANNAH
Middle Name:KATRICE
Last Name:DAVIS-BLOOM
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PLAINVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06062-1904
Mailing Address - Country:US
Mailing Address - Phone:336-918-6033
Mailing Address - Fax:
Practice Address - Street 1:56 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PLAINVILLE
Practice Address - State:CT
Practice Address - Zip Code:06062-1904
Practice Address - Country:US
Practice Address - Phone:336-918-6033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1133103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst