Provider Demographics
NPI:1447916309
Name:WASHBURN, BREANNA G
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:G
Last Name:WASHBURN
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 1:6107 LEWIS ST APT 7205
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-0183
Mailing Address - Country:US
Mailing Address - Phone:207-837-3020
Mailing Address - Fax:
Practice Address - Street 1:6107 LEWIS ST APT 7205
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-0183
Practice Address - Country:US
Practice Address - Phone:207-837-3020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-15
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA17031101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health