Basic Information
| Provider Information | |||||||||
| NPI: | 1386278331 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROWLAND | ||||||||
| FirstName: | BRENNA | ||||||||
| MiddleName: | WYNNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | BCBA | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 17TH ST STE 2 | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347696098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212411170 | ||||||||
| FaxNumber: | 3212411170 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 17TH ST STE 2 | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347696098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212411170 | ||||||||
| FaxNumber: | 3212411170 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2020 | ||||||||
| LastUpdateDate: | 10/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-21-50818 | FL | Y | Behavioral Health & Social Service Providers | Behavioral Analyst | 106S00000X | RBT-20-110998 | FL | N |
ID Information
| ID | Type | State | Issuer | Description | 105862300 | 05 | FL | MEDICAID |