Provider Demographics
NPI:1700083664
Name:BRAWLEY, TABITHA RENEE (MS)
Entity Type:Individual
Prefix:MRS
First Name:TABITHA
Middle Name:RENEE
Last Name:BRAWLEY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MISS
Other - First Name:TABITHA
Other - Middle Name:RENEE
Other - Last Name:BRODAX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:1085 SPRING ST NW
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-7872
Mailing Address - Country:US
Mailing Address - Phone:321-591-8463
Mailing Address - Fax:
Practice Address - Street 1:3040 N WICKHAM RD
Practice Address - Street 2:SUITE #4
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-2369
Practice Address - Country:US
Practice Address - Phone:321-751-1443
Practice Address - Fax:321-751-1448
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ4225235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist