Provider Demographics
NPI:1801325113
Name:BREEDEN, DERRICK STEVEN (DPT)
Entity type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:STEVEN
Last Name:BREEDEN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1855 HIGHWAY 47
Mailing Address - Street 2:
Mailing Address - City:OGILVIE
Mailing Address - State:MN
Mailing Address - Zip Code:56358-9080
Mailing Address - Country:US
Mailing Address - Phone:612-910-1589
Mailing Address - Fax:
Practice Address - Street 1:400 BROADWAY AVE N
Practice Address - Street 2:
Practice Address - City:FOLEY
Practice Address - State:MN
Practice Address - Zip Code:56329-8794
Practice Address - Country:US
Practice Address - Phone:320-968-4677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10647225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist