Provider Demographics
NPI:1801470851
Name:ELIZONDO, BREANA ALEXIS BRADSHAW
Entity type:Individual
Prefix:
First Name:BREANA
Middle Name:ALEXIS BRADSHAW
Last Name:ELIZONDO
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 1:936 HYDRANGEA CIR NW
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-7247
Mailing Address - Country:US
Mailing Address - Phone:469-605-7888
Mailing Address - Fax:
Practice Address - Street 1:3000 LATROBE DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-5226
Practice Address - Country:US
Practice Address - Phone:858-264-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-06
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician