Provider Demographics
NPI:1710666961
Name:BREITHAUPT, AI (LMT)
Entity Type:Individual
Prefix:
First Name:AI
Middle Name:
Last Name:BREITHAUPT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-3326
Mailing Address - Country:US
Mailing Address - Phone:509-525-4160
Mailing Address - Fax:509-522-9921
Practice Address - Street 1:903 HOWARD ST
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-3326
Practice Address - Country:US
Practice Address - Phone:509-525-4160
Practice Address - Fax:509-522-9921
Is Sole Proprietor?:No
Enumeration Date:2023-07-14
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61448804225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist