Provider Demographics
NPI:1306174289
Name:TIVY-DEBAUCHE, BREANNA YOUNG (DC)
Entity type:Individual
Prefix:DR
First Name:BREANNA
Middle Name:YOUNG
Last Name:TIVY-DEBAUCHE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14525 HIGHWAY 7 STE 115
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-3738
Mailing Address - Country:US
Mailing Address - Phone:952-746-5612
Mailing Address - Fax:952-229-4153
Practice Address - Street 1:14525 HIGHWAY 7 STE 115
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55345-3738
Practice Address - Country:US
Practice Address - Phone:952-746-5612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-03
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5299111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor