Healthcare Provider Details

I. General information

NPI: 1174542922
Provider Name (Legal Business Name): JOHN BREEDING PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5306 FORT CLARK DR
AUSTIN TX
78745-2356
US

IV. Provider business mailing address

5306 FORT CLARK DR
AUSTIN TX
78745-2356
US

V. Phone/Fax

Practice location:
  • Phone: 512-799-3610
  • Fax:
Mailing address:
  • Phone: 512-799-3610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number03218
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: