MEDICARE: BRIELLE BRANCH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1164134938
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIELLE BRANCH

Provider Business Mailing Address
First Line	:	300 INTERNATIONAL PKWY STE 200
Second Line	:
City	:	LAKE MARY
State	:	FL
Zip	:	32746-5028
Country	:	US
Telephone Number	:	866-610-0580
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 DUNWOODY PARK STE 200
Second Line	:
City	:	DUNWOODY
State	:	GA
Zip	:	30338-6708
Country	:	US
Telephone Number	:	470-702-9400
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/23/2022
Last Update Date	:	12/23/2022

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Directions to “ BRIELLE BRANCH ” Practice Location

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