Provider Demographics
NPI:1689315483
Name:ROBERTS, BREANNA
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:
Last Name:ROBERTS
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 1:20785 W MCKINNEY AVE
Mailing Address - Street 2:
Mailing Address - City:DUNNELLON
Mailing Address - State:FL
Mailing Address - Zip Code:34431-6418
Mailing Address - Country:US
Mailing Address - Phone:352-342-5006
Mailing Address - Fax:
Practice Address - Street 1:20785 W MCKINNEY AVE
Practice Address - Street 2:
Practice Address - City:DUNNELLON
Practice Address - State:FL
Practice Address - Zip Code:34431-6418
Practice Address - Country:US
Practice Address - Phone:352-342-5006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22-210414106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician