=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902625478
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BREANNA ELISABETH FENIMORE ED.S, NCSP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2024
-----------------------------------------------------
Last Update Date | 10/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 998 GRIZZLY CUB DR
-----------------------------------------------------
City | FRANKLIN
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46131-1375
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-346-8118
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1150 EMERSON POINTE DR APT 1205
-----------------------------------------------------
City | GREENWOOD
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46143-0064
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-334-9126
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number | 10292475
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------