Provider Demographics
NPI:1932215845
Name:BRECHTEL, MARK FRANKLIN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:FRANKLIN
Last Name:BRECHTEL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 SAWDUST TRL
Mailing Address - Street 2:
Mailing Address - City:NICHOLSON
Mailing Address - State:GA
Mailing Address - Zip Code:30565-3097
Mailing Address - Country:US
Mailing Address - Phone:706-372-6199
Mailing Address - Fax:
Practice Address - Street 1:1 HUNTINGTON RD
Practice Address - Street 2:STE 103
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-7204
Practice Address - Country:US
Practice Address - Phone:706-369-0970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2009-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002805103T00000X, 103TC0700X
103TA0400X, 103TC1900X, 103TF0000X, 103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA750409758AMedicaid
GA1162893OtherCAQH
GA68BBGLBMedicare ID - Type Unspecified
GA750409758AMedicaid