Provider Demographics
NPI:1790164283
Name:MINOR, BREANNA JANE
Entity Type:Individual
Prefix:MS
First Name:BREANNA
Middle Name:JANE
Last Name:MINOR
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 1:901 CALEDONIA ST
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54603-2616
Mailing Address - Country:US
Mailing Address - Phone:608-785-4100
Mailing Address - Fax:
Practice Address - Street 1:901 CALEDONIA ST
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54603-2616
Practice Address - Country:US
Practice Address - Phone:608-785-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-29
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4117-154235Z00000X
MN9463235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4117-154OtherWISCONSIN DSPS
MN9463OtherMDH