Provider Demographics
NPI:1629132717
Name:BREAZEAL, JOHN (MS)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:BREAZEAL
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28399 CHAMPIONS DR
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92584-8831
Mailing Address - Country:US
Mailing Address - Phone:951-623-4059
Mailing Address - Fax:
Practice Address - Street 1:9990 COUNTY FARM RD # 6
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3542
Practice Address - Country:US
Practice Address - Phone:951-358-7380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42975106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist