MEDICARE: BREANNA ARIEL SPILLMAN BSW

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	171M00000X	Case Manager/Care Coordinator		OH
2	104100000X	Social Worker		OH

General Provider Information

NPI Number	:	1720699218
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BREANNA ARIEL SPILLMAN BSW

Provider Business Mailing Address
First Line	:	1627 GREENE LAKE DR
Second Line	:
City	:	XENIA
State	:	OH
Zip	:	45385-1534
Country	:	US
Telephone Number	:	937-532-4502
Fax Number	:

Provider Business Practice Location Address
First Line	:	61 S STANFIELD RD
Second Line	:
City	:	TROY
State	:	OH
Zip	:	45373-2992
Country	:	US
Telephone Number	:	937-335-3701
Fax Number	:

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

Provider Enumeration Date	:	08/10/2020
Last Update Date	:	08/10/2020

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