Provider Demographics
NPI:1912537051
Name:MABRY, BREONNA (BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:BREONNA
Middle Name:
Last Name:MABRY
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 1:3107 CABIN RUN
Mailing Address - Street 2:
Mailing Address - City:WOODBINE
Mailing Address - State:MD
Mailing Address - Zip Code:21797-7933
Mailing Address - Country:US
Mailing Address - Phone:760-809-7804
Mailing Address - Fax:
Practice Address - Street 1:3107 CABIN RUN
Practice Address - Street 2:
Practice Address - City:WOODBINE
Practice Address - State:MD
Practice Address - Zip Code:21797-7933
Practice Address - Country:US
Practice Address - Phone:760-809-7804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-16
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT909103K00000X, 222Q00000X
MDLBA885103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist