MEDICARE: MRS. KELLY D BRZAK

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	103K00000X	Behavior Analyst

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386191823
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLY D BRZAK

Provider Business Mailing Address
First Line	:	921 N PENINSULA DR
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32118-3748
Country	:	US
Telephone Number	:	386-444-5742
Fax Number	:

Provider Business Practice Location Address
First Line	:	2400 S RIDGEWOOD AVE STE 17
Second Line	:
City	:	SOUTH DAYTONA
State	:	FL
Zip	:	32119-3073
Country	:	US
Telephone Number	:	386-690-0893
Fax Number	:

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

Provider Enumeration Date	:	09/01/2016
Last Update Date	:	08/19/2021

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