Provider Demographics
NPI:1982354981
Name:DEWILLIS, BRIANNA
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:
Last Name:DEWILLIS
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 1:1430 E GORE ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1418
Mailing Address - Country:US
Mailing Address - Phone:407-591-6769
Mailing Address - Fax:
Practice Address - Street 1:13538 VILLAGE PARK DR STE 145
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-3600
Practice Address - Country:US
Practice Address - Phone:407-730-2948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-24
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL112332500Medicaid