Healthcare Provider Details

I. General information

NPI: 1366012833
Provider Name (Legal Business Name): KENNEDI LARISA BRAZZIEL BCBA, LBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2021
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 HOLCOMB WOODS PKWY STE 320
ROSWELL GA
30076-2587
US

IV. Provider business mailing address

4306 N SHALLOWFORD RD APT 2321
ATLANTA GA
30341-1159
US

V. Phone/Fax

Practice location:
  • Phone: 770-552-1535
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberLBA003235
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: