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General NPI Number Information
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NPI Number | 1790325470
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Entity Type | Individual
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Provider Name | BREEANNA WALLACE LMT, MLD-C
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Gender | Female
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Dates
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Enumeration Date | 01/10/2020
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Last Update Date | 04/30/2025
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Provider Practice Location Address
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Address Line | 180 CLEAR CREEK DR STE 104
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City | ASHLAND
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State | OR
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Zip | 97520-1993
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Country | US
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Telephone | 907-978-8989
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Fax |
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Provider Business Mailing Address
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Address Line | 180 CLEAR CREEK DR STE 104
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City | ASHLAND
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State | OR
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Zip | 97520-1993
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Country | US
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Telephone | 907-978-8989
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Fax | 907-451-9168
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 27902
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License Number State | OR
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