Provider Demographics
NPI:1720755879
Name:BRANTUM, ALECIA
Entity Type:Individual
Prefix:
First Name:ALECIA
Middle Name:
Last Name:BRANTUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1516 E COLONIAL DR STE 306
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-4732
Mailing Address - Country:US
Mailing Address - Phone:407-454-1760
Mailing Address - Fax:407-641-8881
Practice Address - Street 1:1516 E COLONIAL DR STE 306
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-4732
Practice Address - Country:US
Practice Address - Phone:407-454-1760
Practice Address - Fax:407-641-8881
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician