Healthcare Provider Details

I. General information

NPI: 1205958667
Provider Name (Legal Business Name): LAURA MARIE BREESE ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2007
Last Update Date: 05/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137 WINCKLES ST
ELYRIA OH
44035-6151
US

IV. Provider business mailing address

144 STANFORD AVE
ELYRIA OH
44035-6010
US

V. Phone/Fax

Practice location:
  • Phone: 440-366-5993
  • Fax: 440-366-5313
Mailing address:
  • Phone: 440-322-8210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1520
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: