Basic Information
Provider Information | |||||||||
NPI: | 1346584463 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BREESER | ||||||||
FirstName: | MARSHA | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1635 MAPLE LANE | ||||||||
Address2: |   | ||||||||
City: | ASHLAND | ||||||||
State: | WI | ||||||||
PostalCode: | 54806 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7156855400 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1635 MAPLE LN | ||||||||
Address2: |   | ||||||||
City: | ASHLAND | ||||||||
State: | WI | ||||||||
PostalCode: | 548063610 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7156855400 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/15/2012 | ||||||||
LastUpdateDate: | 01/09/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 15604-131 | WI | Y |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | 1608-226 | WI | N |   | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.