Provider Demographics
NPI:1639500572
Name:BREECE, MICAH N
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:N
Last Name:BREECE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 227
Mailing Address - Street 2:400 MAIN STREET
Mailing Address - City:GIDEON
Mailing Address - State:MO
Mailing Address - Zip Code:63848-0227
Mailing Address - Country:US
Mailing Address - Phone:573-448-3447
Mailing Address - Fax:573-448-5197
Practice Address - Street 1:400 N MAIN ST
Practice Address - Street 2:
Practice Address - City:GIDEON
Practice Address - State:MO
Practice Address - Zip Code:63848-9186
Practice Address - Country:US
Practice Address - Phone:573-448-3447
Practice Address - Fax:573-448-5197
Is Sole Proprietor?:No
Enumeration Date:2013-12-03
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001025772235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist