Provider Demographics
NPI:1477045854
Name:BREAZEALE, ASHLEY MAYHEW
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:MAYHEW
Last Name:BREAZEALE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:ANNE
Other - Last Name:MAYHEW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1923 SULPHUR SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37813-5654
Mailing Address - Country:US
Mailing Address - Phone:423-317-9344
Mailing Address - Fax:
Practice Address - Street 1:1754 TEXAS AVE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37921-2513
Practice Address - Country:US
Practice Address - Phone:865-934-6165
Practice Address - Fax:865-342-0165
Is Sole Proprietor?:No
Enumeration Date:2018-06-01
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TNP3741103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program