Provider Demographics
NPI:1396239182
Name:BERES, BREANNE N (DPT, ATC)
Entity type:Individual
Prefix:
First Name:BREANNE
Middle Name:N
Last Name:BERES
Suffix:
Gender:F
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:BREANNE
Other - Middle Name:N
Other - Last Name:GEIPEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT,ATC
Mailing Address - Street 1:1475 W GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-2074
Mailing Address - Country:US
Mailing Address - Phone:262-268-5100
Mailing Address - Fax:
Practice Address - Street 1:1475 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-2074
Practice Address - Country:US
Practice Address - Phone:262-268-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-15
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13882225100000X
2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI06152018736054Medicaid