Provider Demographics
NPI:1013436062
Name:BRELAND, ANDREW J (MS, LPC, BC-TMH, NCC)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:J
Last Name:BRELAND
Suffix:
Gender:M
Credentials:MS, LPC, BC-TMH, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-2312
Mailing Address - Country:US
Mailing Address - Phone:662-883-0331
Mailing Address - Fax:
Practice Address - Street 1:210 E PEACE ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046
Practice Address - Country:US
Practice Address - Phone:662-883-0331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-11
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2281101YP2500X
TX13744101YA0400X
TX75012101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX374571302Medicaid