Healthcare Provider Details

I. General information

NPI: 1306575964
Provider Name (Legal Business Name): BREANNA GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2022
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1446 ETHAN WAY STE 100
SACRAMENTO CA
95825-2235
US

IV. Provider business mailing address

730 SUNRISE AVE
ROSEVILLE CA
95661-4567
US

V. Phone/Fax

Practice location:
  • Phone: 209-342-7353
  • Fax:
Mailing address:
  • Phone: 916-500-3932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number8427
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: