Provider Demographics
NPI:1124626916
Name:BREVARD, WILLIAM III
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:BREVARD
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1645 W PALM LN APT 32
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92802-2022
Mailing Address - Country:US
Mailing Address - Phone:714-926-2370
Mailing Address - Fax:
Practice Address - Street 1:1645 W PALM LN APT 32
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92802-2022
Practice Address - Country:US
Practice Address - Phone:714-926-2370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48803225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist