Provider Demographics
NPI:1629782503
Name:BREAZEALE, KAMRY BOND (LCPC)
Entity Type:Individual
Prefix:
First Name:KAMRY
Middle Name:BOND
Last Name:BREAZEALE
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 CALVIN PURVIS RD
Mailing Address - Street 2:
Mailing Address - City:PURVIS
Mailing Address - State:MS
Mailing Address - Zip Code:39475-4242
Mailing Address - Country:US
Mailing Address - Phone:601-596-5755
Mailing Address - Fax:
Practice Address - Street 1:688 ANTELOPE GAP RD
Practice Address - Street 2:
Practice Address - City:WHEATLAND
Practice Address - State:WY
Practice Address - Zip Code:82201-8810
Practice Address - Country:US
Practice Address - Phone:308-631-6066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-06
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-PCLC-LIC-55453101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional