Provider Demographics
NPI:1417120767
Name:BREAKEY, BEVERLY M (LMFT)
Entity Type:Individual
Prefix:MS
First Name:BEVERLY
Middle Name:M
Last Name:BREAKEY
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 W KETTLEMAN LN
Mailing Address - Street 2:STE R
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242
Mailing Address - Country:US
Mailing Address - Phone:209-334-2053
Mailing Address - Fax:209-334-4149
Practice Address - Street 1:1420 W KETTLEMAN LN
Practice Address - Street 2:STE R
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242
Practice Address - Country:US
Practice Address - Phone:209-334-2053
Practice Address - Fax:209-334-4149
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC30755106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist