Healthcare Provider Details

I. General information

NPI: 1790280329
Provider Name (Legal Business Name): BRIANNE COVERDALE RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2018
Last Update Date: 04/18/2023
Certification Date: 04/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5511 DEEP PURPLE WAY
SAN JOSE CA
95123-1310
US

IV. Provider business mailing address

5511 DEEP PURPLE WAY
SAN JOSE CA
95123-1310
US

V. Phone/Fax

Practice location:
  • Phone: 408-385-5151
  • Fax:
Mailing address:
  • Phone: 408-385-5151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-19-35129
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: