Healthcare Provider Details

I. General information

NPI: 1386464469
Provider Name (Legal Business Name): BREA R MARRIOTT RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2024
Last Update Date: 10/14/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6910 SILVERHEEL ST
SHAWNEE KS
66226-5316
US

IV. Provider business mailing address

6910 SILVERHEEL ST
SHAWNEE KS
66226-5316
US

V. Phone/Fax

Practice location:
  • Phone: 913-405-4550
  • Fax: 913-273-2452
Mailing address:
  • Phone: 913-405-4550
  • Fax: 913-273-2452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number22-225864
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: