Basic Information
| Provider Information | |||||||||
| NPI: | 1467922088 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | BREANNA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9355 W STOCKTON BLVD | ||||||||
| Address2: | UNIT 100 | ||||||||
| City: | ELK GROVE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9166831109 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9355 W STOCKTON BLVD | ||||||||
| Address2: | UNIT 100 | ||||||||
| City: | ELK GROVE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9166831109 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2018 | ||||||||
| LastUpdateDate: | 11/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106E00000X | 0-22-13473 | CA | N | 106S00000X | N | 103K00000X | 1-22-62349 | CA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.