Healthcare Provider Details

I. General information

NPI: 1104277789
Provider Name (Legal Business Name): BRYAN NANEZ BCABA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2016
Last Update Date: 04/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 SAWGRASS CORPORATE PKWY SUITE 106
SUNRISE FL
33325-6244
US

IV. Provider business mailing address

440 SAWGRASS CORPORATE PKWY SUITE 106
SUNRISE FL
33325-6244
US

V. Phone/Fax

Practice location:
  • Phone: 954-745-1112
  • Fax:
Mailing address:
  • Phone: 954-745-1112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-17-8402
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: