Provider Demographics
NPI:1215063193
Name:BREAULT, MARY ANN (LPT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:BREAULT
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1941 HARLEM RD
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-2747
Mailing Address - Country:US
Mailing Address - Phone:815-986-4411
Mailing Address - Fax:815-986-4414
Practice Address - Street 1:1941 HARLEM RD
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-2747
Practice Address - Country:US
Practice Address - Phone:815-986-4411
Practice Address - Fax:815-986-4414
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070009033225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL10132053OtherBCBS PROVIDER NUMBER
IL020654168OtherTAX ID
IL070009033OtherSTATE LISCENSE
IL020654168OtherTAX ID