Provider Demographics
NPI:1174109813
Name:NELSON, BREANNA (MS/EDS)
Entity type:Individual
Prefix:MISS
First Name:BREANNA
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:MS/EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1603 PALM LEAF DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33510-2038
Mailing Address - Country:US
Mailing Address - Phone:321-243-3689
Mailing Address - Fax:
Practice Address - Street 1:1603 PALM LEAF DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33510-2038
Practice Address - Country:US
Practice Address - Phone:321-243-3689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-23
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS1496103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool