Healthcare Provider Details

I. General information

NPI: 1194438382
Provider Name (Legal Business Name): BREYONNA FAWLING
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2023
Last Update Date: 04/21/2025
Certification Date: 04/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96 TOMMY STALNAKER DR STE A
WARNER ROBINS GA
31088-9236
US

IV. Provider business mailing address

3500 DEPAUW BLVD STE 3070
INDIANAPOLIS IN
46268-6135
US

V. Phone/Fax

Practice location:
  • Phone: 478-333-2735
  • Fax: 478-845-7390
Mailing address:
  • Phone: 885-324-0885
  • Fax: 317-520-8200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: