Basic Information
| Provider Information | |||||||||
| NPI: | 1588204218 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORTIN | ||||||||
| FirstName: | BREANNA | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | BCBA., LBA. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FORTIN | ||||||||
| OtherFirstName: | BREANNA | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | BREANNA, MS. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 120 PRECISION STE A-100 | ||||||||
| Address2: | |||||||||
| City: | BUDA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786105925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123544300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 120 PRECISION STE A-100 | ||||||||
| Address2: | |||||||||
| City: | BUDA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786105925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123544300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2020 | ||||||||
| LastUpdateDate: | 01/10/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 3175 | TX | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.