1366670374 NPI number — TETIANA TALYA BREA LMSW

Table of content: TETIANA TALYA BREA LMSW (NPI 1366670374)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366670374 NPI number — TETIANA TALYA BREA LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BREA
Provider First Name:
TETIANA
Provider Middle Name:
TALYA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BREA
Provider Other First Name:
TALYA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMSW
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1366670374
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/29/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
441 EAST AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14607-1932
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-288-3442
Provider Business Mailing Address Fax Number:
585-288-3442

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
441 EAST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14607-1932
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-288-3442
Provider Business Practice Location Address Fax Number:
585-288-3442
Provider Enumeration Date:
06/29/2009

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: 104100000X , with the licence number:  070108-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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