Provider Demographics
NPI:1104697093
Name:BRECKENRIDGE, MOLLIE VIRGINIA JANE
Entity type:Individual
Prefix:
First Name:MOLLIE
Middle Name:VIRGINIA JANE
Last Name:BRECKENRIDGE
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 1:40 CRYSTAL CREEK DR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-5303
Mailing Address - Country:US
Mailing Address - Phone:870-706-0475
Mailing Address - Fax:
Practice Address - Street 1:230 HIGHWAY 5 N STE 10
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-3013
Practice Address - Country:US
Practice Address - Phone:870-404-0270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR202525235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist