Healthcare Provider Details

I. General information

NPI: 1972955086
Provider Name (Legal Business Name): BREANNE BAEZ-COLANTONIO MS, BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2016
Last Update Date: 10/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 E NASA BLVD
MELBOURNE FL
32901
US

IV. Provider business mailing address

125 E NASA BLVD
MELBOURNE FL
32901-1900
US

V. Phone/Fax

Practice location:
  • Phone: 321-372-6813
  • Fax: 321-765-6434
Mailing address:
  • Phone: 321-372-6813
  • Fax: 321-765-6434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-17-41823
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-18-32565
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: