Provider Demographics
NPI:1730370354
Name:BRECKENRIDGE, DARLA K (MED)
Entity type:Individual
Prefix:
First Name:DARLA
Middle Name:K
Last Name:BRECKENRIDGE
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 273
Mailing Address - Street 2:2261 LAKE SHORE RD
Mailing Address - City:ESSEX
Mailing Address - State:NY
Mailing Address - Zip Code:12936-0273
Mailing Address - Country:US
Mailing Address - Phone:518-963-7453
Mailing Address - Fax:
Practice Address - Street 1:2261 LAKE SHORE ROAD
Practice Address - Street 2:
Practice Address - City:ESSEX
Practice Address - State:NY
Practice Address - Zip Code:12936
Practice Address - Country:US
Practice Address - Phone:518-963-7453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-08
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000751101YM0800X
VT103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health