Provider Demographics
NPI:1760216055
Name:BRANHAM, REBECCA ANNE LAREE
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANNE LAREE
Last Name:BRANHAM
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 1:8610 COLSTON CT
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:VA
Mailing Address - Zip Code:20115-3713
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7771 ASHTON AVE
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-2879
Practice Address - Country:US
Practice Address - Phone:833-319-0526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-24-371839106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician