Provider Demographics
NPI:1811614803
Name:BRECKENRIDGE, IAN THOMSON (LPC)
Entity type:Individual
Prefix:MR
First Name:IAN
Middle Name:THOMSON
Last Name:BRECKENRIDGE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1642 WOODS MILL DR
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-2629
Mailing Address - Country:US
Mailing Address - Phone:314-442-5320
Mailing Address - Fax:
Practice Address - Street 1:1642 WOODS MILL DR
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-2629
Practice Address - Country:US
Practice Address - Phone:314-442-5320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-20
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017044140101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health