Provider Demographics
NPI:1922563931
Name:DASH, BREANNA MICHELLE
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:MICHELLE
Last Name:DASH
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 1:3150 ROSWELL RD NW APT 1708
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-2131
Mailing Address - Country:US
Mailing Address - Phone:404-455-9757
Mailing Address - Fax:
Practice Address - Street 1:3150 ROSWELL RD NW APT 1708
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-2131
Practice Address - Country:US
Practice Address - Phone:404-455-9757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-04
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-21-50011103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst