Provider Demographics
NPI:1063168052
Name:MCKINNEY, BREANNE MICHELE
Entity type:Individual
Prefix:
First Name:BREANNE
Middle Name:MICHELE
Last Name:MCKINNEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7101 BRYANT IRVIN RD # 33002
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-4135
Mailing Address - Country:US
Mailing Address - Phone:817-901-1511
Mailing Address - Fax:
Practice Address - Street 1:5530 SW LOOP 820 STE 202
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-1864
Practice Address - Country:US
Practice Address - Phone:817-901-1151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-28
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT120952225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist