Provider Demographics
NPI:1699552778
Name:MCRAE, BREONNA (RBT)
Entity type:Individual
Prefix:
First Name:BREONNA
Middle Name:
Last Name:MCRAE
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:644 TALLULAH TRL
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-7625
Mailing Address - Country:US
Mailing Address - Phone:678-904-7053
Mailing Address - Fax:
Practice Address - Street 1:644 TALLULAH TRL
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-7625
Practice Address - Country:US
Practice Address - Phone:678-904-7053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-12
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-23-297302106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician