Healthcare Provider Details

I. General information

NPI: 1093450991
Provider Name (Legal Business Name): MANDOLYN BREEZE ROREM BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2022
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 S ORANGE ST
NEW SMYRNA BEACH FL
32168-7152
US

IV. Provider business mailing address

311 N ORANGE ST
NEW SMYRNA BEACH FL
32168-6733
US

V. Phone/Fax

Practice location:
  • Phone: 386-402-4460
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: