Basic Information
| Provider Information | |||||||||
| NPI: | 1760953384 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BREESNEE | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | CDP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12715 E MISSION AVE | ||||||||
| Address2: | |||||||||
| City: | SPOKANE VALLEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992161027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092325766 | ||||||||
| FaxNumber: | 5093215472 | ||||||||
| Practice Location | |||||||||
| Address1: | 2308 W. 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096241244 | ||||||||
| FaxNumber: | 5096246240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2018 | ||||||||
| LastUpdateDate: | 07/09/2019 | ||||||||
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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 | 101Y00000X | CO60709233 | WA | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 2077844 | 05 | WA | MEDICAID |