Provider Demographics
NPI:1629400114
Name:BRETON, DEENA MARIE (MA)
Entity Type:Individual
Prefix:MS
First Name:DEENA MARIE
Middle Name:
Last Name:BRETON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MRS
Other - First Name:DEENA MARIE
Other - Middle Name:M
Other - Last Name:BRETON-HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:1121 E STATE ST STE 102A
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6062
Mailing Address - Country:US
Mailing Address - Phone:208-600-5291
Mailing Address - Fax:
Practice Address - Street 1:1121 E STATE ST STE 102A
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6062
Practice Address - Country:US
Practice Address - Phone:208-600-5291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-06
Last Update Date:2023-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLAMFT-6161106H00000X, 106H00000X
ID222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDA0003871Medicaid