Provider Demographics
NPI:1780253633
Name:HENZEN, BREELEY (OD)
Entity type:Individual
Prefix:DR
First Name:BREELEY
Middle Name:
Last Name:HENZEN
Suffix:
Gender:
Credentials:OD
Other - Prefix:
Other - First Name:BREELEY
Other - Middle Name:
Other - Last Name:SELLIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1113 CENTRAL AVE E
Mailing Address - Street 2:
Mailing Address - City:WIGGINS
Mailing Address - State:MS
Mailing Address - Zip Code:39577-9605
Mailing Address - Country:US
Mailing Address - Phone:601-928-3914
Mailing Address - Fax:601-928-2207
Practice Address - Street 1:727 WINTER ST
Practice Address - Street 2:
Practice Address - City:LUCEDALE
Practice Address - State:MS
Practice Address - Zip Code:39452-5949
Practice Address - Country:US
Practice Address - Phone:601-947-2913
Practice Address - Fax:601-766-0212
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-23
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1032152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty