Provider Demographics
NPI:1093243578
Name:BRECKEL, MARY ELLEN (DPT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:BRECKEL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 897
Mailing Address - Street 2:
Mailing Address - City:PORT HADLOCK
Mailing Address - State:WA
Mailing Address - Zip Code:98339-0897
Mailing Address - Country:US
Mailing Address - Phone:360-385-9310
Mailing Address - Fax:360-379-8826
Practice Address - Street 1:27 COLWELL ST
Practice Address - Street 2:
Practice Address - City:PORT HADLOCK
Practice Address - State:WA
Practice Address - Zip Code:98339-9701
Practice Address - Country:US
Practice Address - Phone:360-385-9310
Practice Address - Fax:360-379-8826
Is Sole Proprietor?:No
Enumeration Date:2017-05-30
Last Update Date:2017-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60742259225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist