Provider Demographics
NPI:1982328746
Name:BREEDEN, STEPHANIE MARIE (DPT)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MARIE
Last Name:BREEDEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3623 JANUARY AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109-1502
Mailing Address - Country:US
Mailing Address - Phone:423-506-4353
Mailing Address - Fax:
Practice Address - Street 1:1 JEFFERSON BARRACKS DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63125-4181
Practice Address - Country:US
Practice Address - Phone:314-652-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-26
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070023743225100000X
MO2019042348225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2019042348OtherMISSOURI DIVISION OF PROFESSIONAL REGISTRATION