Provider Demographics
NPI:1831927524
Name:INDIVIDUAL
Entity type:Organization
Organization Name:INDIVIDUAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIOR TECHNICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MIRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRENICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-739-3557
Mailing Address - Street 1:750 FRANKLIN GTWY SE APT 21B
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-7810
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:750 FRANKLIN GTWY SE APT 21B750
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-7807
Practice Address - Country:US
Practice Address - Phone:334-739-3557
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-24
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty