Provider Demographics
NPI:1326179474
Name:BREEDLOVE, LARRY WAYNE
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:WAYNE
Last Name:BREEDLOVE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1906 N JUNIATA ST
Mailing Address - Street 2:
Mailing Address - City:HOLLIDAYSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16648-1908
Mailing Address - Country:US
Mailing Address - Phone:814-695-2984
Mailing Address - Fax:814-695-2110
Practice Address - Street 1:1906 N JUNIATA ST
Practice Address - Street 2:
Practice Address - City:HOLLIDAYSBURG
Practice Address - State:PA
Practice Address - Zip Code:16648-1908
Practice Address - Country:US
Practice Address - Phone:814-695-2984
Practice Address - Fax:814-695-2110
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
PACW0230221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASYC7165OtherSTAFF CODE