Provider Demographics
NPI:1487277976
Name:STUBBS, BREANNA VICTORIA
Entity type:Individual
Prefix:MISS
First Name:BREANNA
Middle Name:VICTORIA
Last Name:STUBBS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7027 SETTERS WAY
Mailing Address - Street 2:
Mailing Address - City:STONECREST
Mailing Address - State:GA
Mailing Address - Zip Code:30038-7502
Mailing Address - Country:US
Mailing Address - Phone:863-999-3910
Mailing Address - Fax:
Practice Address - Street 1:1226 ROYAL DR SW STE D
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-5926
Practice Address - Country:US
Practice Address - Phone:678-658-0645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-19
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC006441101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health