Provider Demographics
NPI:1164965877
Name:BRECKON, AMY (MA, LLP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:BRECKON
Suffix:
Gender:F
Credentials:MA, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8201 ANGLERS LN
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426-8641
Mailing Address - Country:US
Mailing Address - Phone:616-723-3925
Mailing Address - Fax:
Practice Address - Street 1:8201 ANGLERS LN
Practice Address - Street 2:
Practice Address - City:HUDSONVILLE
Practice Address - State:MI
Practice Address - Zip Code:49426-8641
Practice Address - Country:US
Practice Address - Phone:616-723-3925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-29
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008475103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities