Provider Demographics
NPI:1730900473
Name:DEREVJANIK, BRIANNA WINTERS
Entity type:Individual
Prefix:
First Name:BRIANNA
Middle Name:WINTERS
Last Name:DEREVJANIK
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1522 17TH AVE E
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35404-4724
Mailing Address - Country:US
Mailing Address - Phone:207-251-2828
Mailing Address - Fax:
Practice Address - Street 1:1522 17TH AVE E
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35404-4724
Practice Address - Country:US
Practice Address - Phone:207-251-2828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-23
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician