Provider Demographics
NPI:1790280329
Name:COVERDALE, BRIANNE (RBT)
Entity Type:Individual
Prefix:MS
First Name:BRIANNE
Middle Name:
Last Name:COVERDALE
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5511 DEEP PURPLE WAY
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95123-1310
Mailing Address - Country:US
Mailing Address - Phone:408-385-5151
Mailing Address - Fax:
Practice Address - Street 1:5511 DEEP PURPLE WAY
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95123-1310
Practice Address - Country:US
Practice Address - Phone:408-385-5151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-26
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA1-19-35129103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty