Provider Demographics
NPI:1326843855
Name:CHILDS, BREANNA
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:
Last Name:CHILDS
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 1:1061 KEENELAND DR
Mailing Address - Street 2:
Mailing Address - City:BOGART
Mailing Address - State:GA
Mailing Address - Zip Code:30622-4592
Mailing Address - Country:US
Mailing Address - Phone:706-461-1710
Mailing Address - Fax:
Practice Address - Street 1:140 TRINITY PL BLDG B
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30607-2100
Practice Address - Country:US
Practice Address - Phone:770-609-8777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-18
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst