Provider Demographics
NPI:1629287636
Name:BRECKENRIDGE, HOLLY M (LPT)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:M
Last Name:BRECKENRIDGE
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11392 MINER RD
Mailing Address - Street 2:
Mailing Address - City:WEST WINFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:13491-4324
Mailing Address - Country:US
Mailing Address - Phone:315-335-7520
Mailing Address - Fax:
Practice Address - Street 1:2 E PARK ROW
Practice Address - Street 2:STE 1
Practice Address - City:CLINTON
Practice Address - State:NY
Practice Address - Zip Code:13323-1544
Practice Address - Country:US
Practice Address - Phone:315-853-6090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011246-1225100000X
NC6410225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist