MEDICARE: DARLA K BRECKENRIDGE M.ED.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	000751	NY
2	103T00000X	Psychologist		VT

General Provider Information

NPI Number	:	1730370354
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DARLA K BRECKENRIDGE M.ED.

Provider Business Mailing Address
First Line	:	PO BOX 273
Second Line	:	2261 LAKE SHORE RD
City	:	ESSEX
State	:	NY
Zip	:	12936-0273
Country	:	US
Telephone Number	:	518-963-7453
Fax Number	:

Provider Business Practice Location Address
First Line	:	2261 LAKE SHORE ROAD
Second Line	:
City	:	ESSEX
State	:	NY
Zip	:	12936
Country	:	US
Telephone Number	:	518-963-7453
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2007
Last Update Date	:	08/08/2007

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