Provider Demographics
NPI:1609690973
Name:BREEDEN, TANAYAH
Entity type:Individual
Prefix:
First Name:TANAYAH
Middle Name:
Last Name:BREEDEN
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 1:3070 BUSINESS PARK DRIVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30071
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3070 BUSINESS PARK DRIVE
Practice Address - Street 2:SUITE B
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30071
Practice Address - Country:US
Practice Address - Phone:770-884-1050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-13
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-24-387418106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician