Provider Demographics
NPI:1255063525
Name:BREEN, ELISABETH MICHELLE
Entity type:Individual
Prefix:
First Name:ELISABETH
Middle Name:MICHELLE
Last Name:BREEN
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 1:525 W AVENUE P4
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93551-3743
Mailing Address - Country:US
Mailing Address - Phone:213-342-0150
Mailing Address - Fax:
Practice Address - Street 1:525 W AVENUE P4
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551-3743
Practice Address - Country:US
Practice Address - Phone:661-733-3548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-27
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
APCC17604101YP2500X
CAAMFT149142106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional