Provider Demographics
NPI:1669154415
Name:KIRKLAND, BREASIA
Entity type:Individual
Prefix:
First Name:BREASIA
Middle Name:
Last Name:KIRKLAND
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 1:7016 CORPORATE WAY
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON TOWNSHIP
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4300
Mailing Address - Country:US
Mailing Address - Phone:937-951-2084
Mailing Address - Fax:
Practice Address - Street 1:7016 CORPORATE WAY
Practice Address - Street 2:
Practice Address - City:WASHINGTON TOWNSHIP
Practice Address - State:OH
Practice Address - Zip Code:45459-4300
Practice Address - Country:US
Practice Address - Phone:937-951-2084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-02
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2910854Medicaid