Healthcare Provider Details

I. General information

NPI: 1659943496
Provider Name (Legal Business Name): ANDREA M BREAZEALE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2021
Last Update Date: 07/12/2021
Certification Date: 07/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 AUSTIN GRAYBILL RD
NORTH AUGUSTA SC
29860-9251
US

IV. Provider business mailing address

4 INDIAN ROCK CT
NORTH AUGUSTA SC
29841-5214
US

V. Phone/Fax

Practice location:
  • Phone: 803-278-4272
  • Fax:
Mailing address:
  • Phone: 803-215-1922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number4452
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: