Provider Demographics
NPI:1124751573
Name:DEPALO, BRIANNA LYNN
Entity type:Individual
Prefix:
First Name:BRIANNA
Middle Name:LYNN
Last Name:DEPALO
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 1:10655 COLLEGE HILL AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89166-6562
Mailing Address - Country:US
Mailing Address - Phone:631-782-4376
Mailing Address - Fax:
Practice Address - Street 1:2340 W HORIZON RIDGE PKWY
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-5074
Practice Address - Country:US
Practice Address - Phone:702-610-2076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-04
Last Update Date:2022-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV617659103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst