1083274534 NPI number — BREANA J SEUFFER MA, LPC-IT, SAC-IT

Table of content: BREANA J SEUFFER MA, LPC-IT, SAC-IT (NPI 1083274534)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083274534 NPI number — BREANA J SEUFFER MA, LPC-IT, SAC-IT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SEUFFER
Provider First Name:
BREANA
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, LPC-IT, SAC-IT
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:
1083274534
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 386
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POY SIPPI
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54967-0386
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-379-0009
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
W2333 COMMERCIAL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POY SIPPI
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54967-8108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-379-0009
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/17/2019

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: 101YP2500X , with the licence number:  8115-125 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YA0400X , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 100091871 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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