1922520410 NPI number — CLARESSA SUE BREKKE PT, DPT

Table of content: CLARESSA SUE BREKKE PT, DPT (NPI 1922520410)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922520410 NPI number — CLARESSA SUE BREKKE PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BREKKE
Provider First Name:
CLARESSA
Provider Middle Name:
SUE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922520410
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1795 ALYSHEBA WAY STE 3202
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40509-2280
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-264-8868
Provider Business Mailing Address Fax Number:
859-264-8878

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1316 MINNICH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW HAVEN
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46774
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-748-4864
Provider Business Practice Location Address Fax Number:
260-749-5960
Provider Enumeration Date:
07/17/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT012951 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 05013243A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)