Provider Demographics
NPI:1184059941
Name:FOX, BREANN FAYE (DPT)
Entity type:Individual
Prefix:
First Name:BREANN
Middle Name:FAYE
Last Name:FOX
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:BREANN
Other - Middle Name:FAYE
Other - Last Name:SUDDOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:10115 E BELL RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-2189
Mailing Address - Country:US
Mailing Address - Phone:480-419-3500
Mailing Address - Fax:
Practice Address - Street 1:120 E PINE ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4836
Practice Address - Country:US
Practice Address - Phone:208-454-5142
Practice Address - Fax:208-454-5148
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-11
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10524225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPT-5245OtherSTATE LICENSE