Provider Demographics
NPI:1427609569
Name:FORT, BREANNA SUZANNE (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:SUZANNE
Last Name:FORT
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3626 LOWER HONOAPIILANI RD APT C302
Mailing Address - Street 2:
Mailing Address - City:LAHAINA
Mailing Address - State:HI
Mailing Address - Zip Code:96761-8992
Mailing Address - Country:US
Mailing Address - Phone:610-716-7009
Mailing Address - Fax:
Practice Address - Street 1:100 AKAHELE ST
Practice Address - Street 2:
Practice Address - City:LAHAINA
Practice Address - State:HI
Practice Address - Zip Code:96761-9395
Practice Address - Country:US
Practice Address - Phone:808-662-3955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-20
Last Update Date:2024-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEO1-0001777235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist