Provider Demographics
NPI:1548716392
Name:BREDER, KELSEANNE
Entity type:Individual
Prefix:
First Name:KELSEANNE
Middle Name:
Last Name:BREDER
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 1:100 HAVEN AVE
Mailing Address - Street 2:25D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-2645
Mailing Address - Country:US
Mailing Address - Phone:407-697-6254
Mailing Address - Fax:
Practice Address - Street 1:100 HAVEN AVE
Practice Address - Street 2:25D
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032
Practice Address - Country:US
Practice Address - Phone:407-697-6254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-31
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY709514163WP0808X
NY402383363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health