Provider Demographics
NPI:1497847164
Name:BREEN, KERRY A (MPT)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:A
Last Name:BREEN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1977 DEWAR DR STE J
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-5757
Mailing Address - Country:US
Mailing Address - Phone:307-382-3228
Mailing Address - Fax:
Practice Address - Street 1:1977 DEWAR DR STE J
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-5757
Practice Address - Country:US
Practice Address - Phone:307-382-3228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT-853225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY315268OtherBLUE CROSS BLUE SHIELD
WA179483OtherWORK COMP
WY117566100Medicaid
WA179483OtherWORK COMP
WY315268OtherBLUE CROSS BLUE SHIELD
WYW9682Medicare PIN