Healthcare Provider Details

I. General information

NPI: 1508192287
Provider Name (Legal Business Name): MONTA ANNETTE BREEDEN LCSW LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2009
Last Update Date: 09/27/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 JOEL DR
FORT CAMPBELL KY
42223-5318
US

IV. Provider business mailing address

7024 RHODES AVENUE
ST. LOUIS MO
63123
US

V. Phone/Fax

Practice location:
  • Phone: 270-798-8400
  • Fax: 270-798-8224
Mailing address:
  • Phone: 615-239-9562
  • Fax: 270-798-8224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberKY-3190
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number005085
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberKY-3190
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2022049235
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: