Provider Demographics
NPI:1225363849
Name:BREITBORDE, NICHOLAS JK (PHD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JK
Last Name:BREITBORDE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:NICHOLAS
Other - Middle Name:
Other - Last Name:BREITBORDE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:700 ACKERMAN RD STE 2120
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-293-8234
Mailing Address - Fax:
Practice Address - Street 1:1670 UPHAM DR
Practice Address - Street 2:STE 130
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1250
Practice Address - Country:US
Practice Address - Phone:614-293-8234
Practice Address - Fax:614-293-8552
Is Sole Proprietor?:No
Enumeration Date:2009-10-15
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4063103TF0000X, 103TC2200X, 103TF0000X, 103TP2701X
OH7267103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0132375Medicaid