Provider Demographics
NPI:1104277789
Name:NANEZ, BRYAN (BCABA)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:NANEZ
Suffix:
Gender:M
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 SAWGRASS CORPORATE PKWY
Mailing Address - Street 2:SUITE 106
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33325-6244
Mailing Address - Country:US
Mailing Address - Phone:954-745-1112
Mailing Address - Fax:
Practice Address - Street 1:440 SAWGRASS CORPORATE PKWY
Practice Address - Street 2:SUITE 106
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33325-6244
Practice Address - Country:US
Practice Address - Phone:954-745-1112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-25
Last Update Date:2019-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TB0200X
FL0-17-8402106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral