Healthcare Provider Details

I. General information

NPI: 1548118268
Provider Name (Legal Business Name): FANTASTICALLY BRILLIANT INDIVIDUALS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2026
Last Update Date: 03/18/2026
Certification Date: 03/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S BRANTLEY ST
TROY AL
36081
US

IV. Provider business mailing address

208 LEGACY DR
ENTERPRISE AL
36330-4440
US

V. Phone/Fax

Practice location:
  • Phone: 334-464-0717
  • Fax: 334-464-0717
Mailing address:
  • Phone: 334-464-0717
  • Fax: 334-464-0717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: CHARLES WESTRICK
Title or Position: OWNER
Credential:
Phone: 334-464-0717