MEDICARE: DR. SUE A. BREEDEN PH.D., LP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	LP2625	MN

General Provider Information

NPI Number	:	1588757751
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUE A. BREEDEN PH.D., LP

Provider Business Mailing Address
First Line	:	5125 PORTLAND AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55417-1747
Country	:	US
Telephone Number	:	612-599-8585
Fax Number	:

Provider Business Practice Location Address
First Line	:	2431 HENNEPIN AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55405-2605
Country	:	US
Telephone Number	:	612-746-8536
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	07/09/2007

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