Provider Demographics
NPI:1881048924
Name:MCGOWAN, BREANNA
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:
Last Name:MCGOWAN
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 1:260 VILLAGE CREEK CIR APT H
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-4799
Mailing Address - Country:US
Mailing Address - Phone:980-439-0230
Mailing Address - Fax:
Practice Address - Street 1:4401 PROVIDENCE LN STE 121
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3226
Practice Address - Country:US
Practice Address - Phone:336-896-1323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-14
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10907104100000X
NCP0094911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker