Provider Demographics
NPI:1962956474
Name:RICHARDSON, BREANNA (SLP)
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2279 ATKINSON RD
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39531-2209
Mailing Address - Country:US
Mailing Address - Phone:228-388-1805
Mailing Address - Fax:
Practice Address - Street 1:2030 CHILHOWEE MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-5285
Practice Address - Country:US
Practice Address - Phone:865-982-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-12
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4067235Z00000X
MSS3878235Z00000X
TN6742235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ071423Medicaid