Healthcare Provider Details

I. General information

NPI: 1295657070
Provider Name (Legal Business Name): RENAE MORVLEE JODIAN BROWN ECCLESTON
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 10TH AVE
SHALIMAR FL
32579-1340
US

IV. Provider business mailing address

1803 TREELINE CT
FORT WALTON BEACH FL
32547-6031
US

V. Phone/Fax

Practice location:
  • Phone: 810-336-3218
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: