Healthcare Provider Details

I. General information

NPI: 1689199796
Provider Name (Legal Business Name): MRS. BREANNA VICTORIA CALKINS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2017
Last Update Date: 01/21/2023
Certification Date: 01/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 HAZEN RD
DELAND FL
32720-2603
US

IV. Provider business mailing address

660 HAZEN RD
DELAND FL
32720-2603
US

V. Phone/Fax

Practice location:
  • Phone: 386-490-6768
  • Fax:
Mailing address:
  • Phone: 386-490-6768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSI3352
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA16635
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSZ8379
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: