Provider Demographics
NPI:1982383667
Name:BLANKEN, BREANNA FAITH (RBT)
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:FAITH
Last Name:BLANKEN
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 CLEARWATER LARGO RD N LOT 16A
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33770-2361
Mailing Address - Country:US
Mailing Address - Phone:321-917-9254
Mailing Address - Fax:
Practice Address - Street 1:620 CLEARWATER LARGO RD N LOT 16A
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-2361
Practice Address - Country:US
Practice Address - Phone:321-917-9254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-11
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYRBT-23-272200106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician