Provider Demographics
NPI:1558414508
Name:BREISINGER, GARY DONALD (MA)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:DONALD
Last Name:BREISINGER
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 PITTSBURGH ST
Mailing Address - Street 2:P.O. BOX 94
Mailing Address - City:SPRINGDALE
Mailing Address - State:PA
Mailing Address - Zip Code:15144-1620
Mailing Address - Country:US
Mailing Address - Phone:724-274-0834
Mailing Address - Fax:
Practice Address - Street 1:825 PITTSBURGH ST
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:PA
Practice Address - Zip Code:15144-1620
Practice Address - Country:US
Practice Address - Phone:724-274-0834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS003377L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018201000002Medicaid
PA280039OtherVALUE OPTIONS
PAR07576Medicare UPIN
PA0018201000002Medicaid