=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114508819
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRITTANY GRACE NORMAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2021
-----------------------------------------------------
Last Update Date | 04/15/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2790 KELLER HICKS RD
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76244-9610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-526-0383
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1036 IRENE ST
-----------------------------------------------------
City | BURLESON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76028-6446
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-526-0383
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number | RBT-19-86719
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------