Provider Demographics
NPI:1699846154
Name:BREITENBUCHER, THOMAS ARTHUR (PHD, LP)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:ARTHUR
Last Name:BREITENBUCHER
Suffix:
Gender:M
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6120 EARLE BROWN DR
Mailing Address - Street 2:SUITE 520
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55430-2123
Mailing Address - Country:US
Mailing Address - Phone:763-531-0566
Mailing Address - Fax:763-531-0602
Practice Address - Street 1:6120 EARLE BROWN DR
Practice Address - Street 2:SUITE 520
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55430-2123
Practice Address - Country:US
Practice Address - Phone:763-531-0566
Practice Address - Fax:763-531-0602
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2794101YM0800X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN104654OtherUCARE
MN54R37BROtherBLUECROSSBLUESHIELD
MN433853700Medicaid
MN61-16175OtherMEDICA
MN104654OtherUCARE