Provider Demographics
NPI:1043503592
Name:BREAZEAL, CARLA R (COTA)
Entity Type:Individual
Prefix:MRS
First Name:CARLA
Middle Name:R
Last Name:BREAZEAL
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 JOSEPHINE ST
Mailing Address - Street 2:
Mailing Address - City:SWEETWATER
Mailing Address - State:TX
Mailing Address - Zip Code:79556-3418
Mailing Address - Country:US
Mailing Address - Phone:832-585-7940
Mailing Address - Fax:
Practice Address - Street 1:1201 JOSEPHINE ST
Practice Address - Street 2:
Practice Address - City:SWEETWATER
Practice Address - State:TX
Practice Address - Zip Code:79556-3418
Practice Address - Country:US
Practice Address - Phone:832-585-7940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-17
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210487172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker