Healthcare Provider Details

I. General information

NPI: 1851991681
Provider Name (Legal Business Name): MATTHEW BREIDING PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2020
Last Update Date: 10/30/2020
Certification Date: 10/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3103 CLAIRMONT RD NE STE B
BROOKHAVEN GA
30329-1043
US

IV. Provider business mailing address

5325 COUNTRY LAKE CT SW
LILBURN GA
30047-6760
US

V. Phone/Fax

Practice location:
  • Phone: 404-486-9034
  • Fax:
Mailing address:
  • Phone: 245-535-7939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPS-T001070
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: