Provider Demographics
NPI:1104622141
Name:BEAUVAIS, BREGARD ANDERSON
Entity type:Individual
Prefix:
First Name:BREGARD
Middle Name:ANDERSON
Last Name:BEAUVAIS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6521 ALADDIN DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32818-1369
Mailing Address - Country:US
Mailing Address - Phone:321-746-6746
Mailing Address - Fax:
Practice Address - Street 1:6521 ALADDIN DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32818-1369
Practice Address - Country:US
Practice Address - Phone:321-746-6746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-20
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLB630-040-68-100-0106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician