Provider Demographics
NPI:1467529032
Name:BREEDEN, CANDICE RHEA (PTA)
Entity Type:Individual
Prefix:MS
First Name:CANDICE
Middle Name:RHEA
Last Name:BREEDEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5146 STAGE RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38134-3164
Mailing Address - Country:US
Mailing Address - Phone:901-380-2727
Mailing Address - Fax:901-380-2722
Practice Address - Street 1:5146 STAGE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38134-3164
Practice Address - Country:US
Practice Address - Phone:901-380-2727
Practice Address - Fax:901-380-2722
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPTA0000003613225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN183838OtherBLUE CROSS PROVIDER
TN446538Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER