Healthcare Provider Details

I. General information

NPI: 1124831482
Provider Name (Legal Business Name): BRENNAN PAUL MELANCON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2025
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15048 14TH ST
DADE CITY FL
33523-2503
US

IV. Provider business mailing address

9571 SOUTHERN CHARM CIR
BROOKSVILLE FL
34613-6831
US

V. Phone/Fax

Practice location:
  • Phone: 813-759-3555
  • Fax:
Mailing address:
  • Phone: 813-759-3555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: