MEDICARE: LEATRICE BRAZELL

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		GA

General Provider Information

NPI Number	:	1316828676
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEATRICE BRAZELL

Provider Business Mailing Address
First Line	:	1116 FLORA ST
Second Line	:
City	:	MOUNT VERNON
State	:	GA
Zip	:	30445-2756
Country	:	US
Telephone Number	:	478-595-3170
Fax Number	:

Provider Business Practice Location Address
First Line	:	1116 FLORA ST
Second Line	:
City	:	MOUNT VERNON
State	:	GA
Zip	:	30445-2756
Country	:	US
Telephone Number	:	478-595-3170
Fax Number	:

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

Provider Enumeration Date	:	09/11/2025
Last Update Date	:	09/11/2025

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Directions to “ LEATRICE BRAZELL ” Practice Location

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