Provider Demographics
NPI:1518963362
Name:BRELAND, WILLIAM HUGH
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:HUGH
Last Name:BRELAND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1337 GUSDORF RD
Mailing Address - Street 2:STE I
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-7200
Mailing Address - Country:US
Mailing Address - Phone:505-641-4768
Mailing Address - Fax:575-758-1810
Practice Address - Street 1:208 S RED RIVER EXPY
Practice Address - Street 2:STE E
Practice Address - City:BURKBURNETT
Practice Address - State:TX
Practice Address - Zip Code:76354-3752
Practice Address - Country:US
Practice Address - Phone:940-569-3630
Practice Address - Fax:940-569-3752
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX752803659174400000X, 1744R1103X
NM4674225100000X
TX1011591225100000X
OK2429225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist
No1744R1103XOther Service ProvidersSpecialistResearch Data Abstracter/Coder
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX167449101Medicaid
OK100835690AMedicaid