Provider Demographics
NPI:1770121857
Name:HENDERSON, BREANNA CHANNEL
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:CHANNEL
Last Name:HENDERSON
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 1:14150 ECON WOODS LN
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32826-6417
Mailing Address - Country:US
Mailing Address - Phone:407-219-8597
Mailing Address - Fax:
Practice Address - Street 1:3305 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-6125
Practice Address - Country:US
Practice Address - Phone:407-852-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-19
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist