Provider Demographics
NPI:1073255394
Name:BRECKENRIDGE, ALEXIS EMILY
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:EMILY
Last Name:BRECKENRIDGE
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 1:11392 MINER RD
Mailing Address - Street 2:
Mailing Address - City:WEST WINFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:13491-4324
Mailing Address - Country:US
Mailing Address - Phone:315-335-0468
Mailing Address - Fax:
Practice Address - Street 1:700 W 40TH ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21211-2140
Practice Address - Country:US
Practice Address - Phone:410-235-8860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-07
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA225X00000X
MD09874225X00000X
NY026265-01225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist