Provider Demographics
NPI:1982194270
Name:BREEN, CARLIE ALEXIS (RBT 17-40767)
Entity Type:Individual
Prefix:
First Name:CARLIE
Middle Name:ALEXIS
Last Name:BREEN
Suffix:
Gender:F
Credentials:RBT 17-40767
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22477 CUNNINGHAM AVE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48091-3635
Mailing Address - Country:US
Mailing Address - Phone:586-335-5455
Mailing Address - Fax:
Practice Address - Street 1:22477 CUNNINGHAM AVE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48091-3635
Practice Address - Country:US
Practice Address - Phone:586-335-5455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-13
Last Update Date:2018-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI17-40767106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician