Provider Demographics
NPI:1467345652
Name:SHORT, BREANA NICOLE
Entity type:Individual
Prefix:
First Name:BREANA
Middle Name:NICOLE
Last Name:SHORT
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:PO BOX 2572
Mailing Address - Street 2:
Mailing Address - City:LINDALE
Mailing Address - State:TX
Mailing Address - Zip Code:75771-8672
Mailing Address - Country:US
Mailing Address - Phone:903-636-7994
Mailing Address - Fax:
Practice Address - Street 1:14864 COUNTY ROAD 433
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75706-3206
Practice Address - Country:US
Practice Address - Phone:903-636-7994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-29
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician