Provider Demographics
NPI:1932864303
Name:STUCKEY, BREIONNA RENAE
Entity Type:Individual
Prefix:
First Name:BREIONNA
Middle Name:RENAE
Last Name:STUCKEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BREIONNA
Other - Middle Name:RENAE
Other - Last Name:BAUMGRAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1055 E COLORADO BLVD STE 560
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-2380
Mailing Address - Country:US
Mailing Address - Phone:989-472-7836
Mailing Address - Fax:
Practice Address - Street 1:612 W LAKE LANSING RD STE 400
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-8528
Practice Address - Country:US
Practice Address - Phone:888-805-0759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-01
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician