Provider Demographics
NPI:1558035196
Name:BREDA, GLENN (LMT)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:BREDA
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 ATLANTIC ST UNIT 301
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06604-5269
Mailing Address - Country:US
Mailing Address - Phone:203-953-2722
Mailing Address - Fax:
Practice Address - Street 1:850 ATLANTIC ST UNIT 301
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06604-5269
Practice Address - Country:US
Practice Address - Phone:203-953-2722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-06
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225700000X
CT001456225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist