Provider Demographics
NPI:1801243282
Name:BREACH, SANDRA JO (MSW)
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:JO
Last Name:BREACH
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:MRS
Other - First Name:SANDRA
Other - Middle Name:JO
Other - Last Name:SHYBUT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:2611 ANNA AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH PLATTE
Mailing Address - State:NE
Mailing Address - Zip Code:69101-4495
Mailing Address - Country:US
Mailing Address - Phone:308-530-5921
Mailing Address - Fax:
Practice Address - Street 1:108 EAST 2ND STREET
Practice Address - Street 2:
Practice Address - City:NORTH PLATTE
Practice Address - State:NE
Practice Address - Zip Code:69101-0000
Practice Address - Country:US
Practice Address - Phone:308-534-9271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-16
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE16851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical