Provider Demographics
NPI:1790325470
Name:WALLACE, BREEANNA (LMT, MLD-C)
Entity type:Individual
Prefix:
First Name:BREEANNA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:
Credentials:LMT, MLD-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 CLEAR CREEK DR STE 104
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-1993
Mailing Address - Country:US
Mailing Address - Phone:907-978-8989
Mailing Address - Fax:907-451-9168
Practice Address - Street 1:180 CLEAR CREEK DR STE 104
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-1993
Practice Address - Country:US
Practice Address - Phone:907-978-8989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-10
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR27902225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1437273125OtherNPI