Provider Demographics
NPI:1972955086
Name:BAEZ-COLANTONIO, BREANNE (MS, BCBA)
Entity type:Individual
Prefix:
First Name:BREANNE
Middle Name:
Last Name:BAEZ-COLANTONIO
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 E NASA BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-1900
Mailing Address - Country:US
Mailing Address - Phone:321-372-6813
Mailing Address - Fax:321-765-6434
Practice Address - Street 1:125 E NASA BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901
Practice Address - Country:US
Practice Address - Phone:321-372-6813
Practice Address - Fax:321-765-6434
Is Sole Proprietor?:No
Enumeration Date:2016-07-13
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-17-41823106S00000X, 106S00000X
FL1-18-32565103K00000X
247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022112800Medicaid