Provider Demographics
NPI:1861192825
Name:BREESE, TYLER MATTHEW (LCMHCA)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:MATTHEW
Last Name:BREESE
Suffix:
Gender:M
Credentials:LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:ROCKWELL
Mailing Address - State:NC
Mailing Address - Zip Code:28138-7796
Mailing Address - Country:US
Mailing Address - Phone:336-688-8363
Mailing Address - Fax:
Practice Address - Street 1:311 WILLIAMSON RD STE 103
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-5967
Practice Address - Country:US
Practice Address - Phone:704-360-3049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-08
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA18594101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional