Provider Demographics
NPI:1003433715
Name:PEDERSEN, BREANNE ASHLY
Entity Type:Individual
Prefix:
First Name:BREANNE
Middle Name:ASHLY
Last Name:PEDERSEN
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 1:265 STONEGATE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-5614
Mailing Address - Country:US
Mailing Address - Phone:224-678-9180
Mailing Address - Fax:224-678-9369
Practice Address - Street 1:265 STONEGATE RD STE 102
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102-5614
Practice Address - Country:US
Practice Address - Phone:224-678-9180
Practice Address - Fax:224-678-9369
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-29
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178015896101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional