Provider Demographics
NPI:1831636794
Name:PAULINE, BREANA ASHLEY (MS)
Entity Type:Individual
Prefix:MS
First Name:BREANA
Middle Name:ASHLEY
Last Name:PAULINE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6553
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33807-6553
Mailing Address - Country:US
Mailing Address - Phone:863-602-0698
Mailing Address - Fax:
Practice Address - Street 1:10150 HIGHLAND MANOR DR STE 200
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-9712
Practice Address - Country:US
Practice Address - Phone:813-602-0068
Practice Address - Fax:813-354-2715
Is Sole Proprietor?:No
Enumeration Date:2017-01-30
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-20-42304103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst