Provider Demographics
NPI:1306255989
Name:BREITBARTH, THOMAS
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:
Last Name:BREITBARTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1713 FORT JESSE RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-6208
Mailing Address - Country:US
Mailing Address - Phone:309-862-2225
Mailing Address - Fax:309-862-2229
Practice Address - Street 1:1713 FORT JESSE RD
Practice Address - Street 2:SUITE D
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-6208
Practice Address - Country:US
Practice Address - Phone:309-862-2225
Practice Address - Fax:309-862-2229
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-07
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.000305225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist