Provider Demographics
NPI:1063466290
Name:BREITUNG, TERRY L (OT)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:L
Last Name:BREITUNG
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 S SAGE AVE
Mailing Address - Street 2:STE. B
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36606-3616
Mailing Address - Country:US
Mailing Address - Phone:251-470-7772
Mailing Address - Fax:251-470-7773
Practice Address - Street 1:316 S SAGE AVE
Practice Address - Street 2:STE. B
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36606-3616
Practice Address - Country:US
Practice Address - Phone:251-470-7772
Practice Address - Fax:251-470-7773
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL0414174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALL172OtherMEDICARE GROUP
AL51079428OtherBCBS
AL000079428Medicare ID - Type UnspecifiedMEDICARE
ALL172OtherMEDICARE GROUP