Basic Information
| Provider Information | |||||||||
| NPI: | 1467922807 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRECK | ||||||||
| FirstName: | HARLIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | COTA/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 920 4TH ST | ||||||||
| Address2: | |||||||||
| City: | GARRETSON | ||||||||
| State: | SD | ||||||||
| PostalCode: | 570302006 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 920 4TH ST | ||||||||
| Address2: | |||||||||
| City: | GARRETSON | ||||||||
| State: | SD | ||||||||
| PostalCode: | 570305703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6055943466 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2018 | ||||||||
| LastUpdateDate: | 11/28/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 405300000X | 408A | SD | Y |
No ID Information.