Provider Demographics
NPI:1467177055
Name:HILLSTROM, BREEDEN (MA)
Entity Type:Individual
Prefix:
First Name:BREEDEN
Middle Name:
Last Name:HILLSTROM
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19916 OLD OWEN RD # 152
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-9778
Mailing Address - Country:US
Mailing Address - Phone:360-485-0820
Mailing Address - Fax:949-404-8981
Practice Address - Street 1:101 E MAIN ST STE 208
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1519
Practice Address - Country:US
Practice Address - Phone:360-485-0820
Practice Address - Fax:949-404-8981
Is Sole Proprietor?:No
Enumeration Date:2022-10-06
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101Y00000X
WACG61346774101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor