Provider Demographics
NPI:1881933851
Name:BRECKENRIDGE, CAROL MARQUIS (LMSW)
Entity type:Individual
Prefix:MS
First Name:CAROL
Middle Name:MARQUIS
Last Name:BRECKENRIDGE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3505 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3011
Mailing Address - Country:US
Mailing Address - Phone:928-757-8111
Mailing Address - Fax:928-757-1192
Practice Address - Street 1:3505 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3011
Practice Address - Country:US
Practice Address - Phone:928-757-8111
Practice Address - Fax:928-757-1192
Is Sole Proprietor?:No
Enumeration Date:2013-02-11
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10684104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker