Healthcare Provider Details

I. General information

NPI: 1689259145
Provider Name (Legal Business Name): BREANNAH KATRICE DAVIS-BLOOM BCBA, LBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2021
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CARRIAGE LN STE 102
CHARLESTON SC
29407-6060
US

IV. Provider business mailing address

1 CARRIAGE LN STE 102
CHARLESTON SC
29407-6060
US

V. Phone/Fax

Practice location:
  • Phone: 843-256-8188
  • Fax:
Mailing address:
  • Phone: 843-256-8188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: