Provider Demographics
NPI:1194438382
Name:FAWLING, BREYONNA
Entity type:Individual
Prefix:
First Name:BREYONNA
Middle Name:
Last Name:FAWLING
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:885-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:96 TOMMY STALNAKER DR STE A
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-9236
Practice Address - Country:US
Practice Address - Phone:478-333-2735
Practice Address - Fax:478-845-7390
Is Sole Proprietor?:No
Enumeration Date:2023-01-03
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
GA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician