Provider Demographics
NPI:1255636890
Name:BREEDEN, LAURIE A
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:A
Last Name:BREEDEN
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 1:6709 PIKE BEND RD
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:WI
Mailing Address - Zip Code:54893-8610
Mailing Address - Country:US
Mailing Address - Phone:715-866-8356
Mailing Address - Fax:
Practice Address - Street 1:205 UNITED WAY
Practice Address - Street 2:
Practice Address - City:FREDERIC
Practice Address - State:WI
Practice Address - Zip Code:54837-8938
Practice Address - Country:US
Practice Address - Phone:715-327-4297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-12
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI623-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant