Provider Demographics
NPI:1881270080
Name:GROTZINGER, BREANNA CHRISTINE (MED)
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:CHRISTINE
Last Name:GROTZINGER
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:BREEZY
Other - Middle Name:
Other - Last Name:GROTZINGER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2012 CHERRY HILL DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-5882
Mailing Address - Country:US
Mailing Address - Phone:573-819-1330
Mailing Address - Fax:
Practice Address - Street 1:2012 CHERRY HILL DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-5882
Practice Address - Country:US
Practice Address - Phone:573-819-1330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-19
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20190450070101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional