Provider Demographics
NPI:1093886723
Name:BREY, DOUGLAS CLYDE (LLP)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:CLYDE
Last Name:BREY
Suffix:
Gender:M
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-5030
Mailing Address - Country:US
Mailing Address - Phone:920-236-4700
Mailing Address - Fax:920-236-1157
Practice Address - Street 1:220 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-5030
Practice Address - Country:US
Practice Address - Phone:920-236-4700
Practice Address - Fax:920-236-1157
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011664103TB0200X
WI4871101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral