Provider Demographics
NPI:1821089632
Name:BREITENBACH, DEIDRA (PT)
Entity Type:Individual
Prefix:
First Name:DEIDRA
Middle Name:
Last Name:BREITENBACH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422-2090
Mailing Address - Country:US
Mailing Address - Phone:859-236-7012
Mailing Address - Fax:859-236-7407
Practice Address - Street 1:321 S 3RD ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-2090
Practice Address - Country:US
Practice Address - Phone:859-236-7012
Practice Address - Fax:859-236-7407
Is Sole Proprietor?:No
Enumeration Date:2005-11-01
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY002215225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY87001574Medicaid
KY87001574Medicaid
KY0588206Medicare ID - Type UnspecifiedLANCASTER CLINIC