Provider Demographics
NPI:1245564756
Name:BREITENBACH, MARCIA
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:
Last Name:BREITENBACH
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 1:3535 W PLACITA DE LA TIERRA
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85746-2176
Mailing Address - Country:US
Mailing Address - Phone:520-975-5376
Mailing Address - Fax:
Practice Address - Street 1:3535 W PLACITA DE LA TIERRA
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85746-2176
Practice Address - Country:US
Practice Address - Phone:520-975-5376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-30
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-1325101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional