Provider Demographics
NPI:1215332358
Name:BREAULT, DONNA (LADC)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:BREAULT
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-5326
Mailing Address - Country:US
Mailing Address - Phone:603-998-4210
Mailing Address - Fax:603-532-0720
Practice Address - Street 1:90 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-5326
Practice Address - Country:US
Practice Address - Phone:603-998-4210
Practice Address - Fax:603-532-0720
Is Sole Proprietor?:No
Enumeration Date:2014-10-31
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0892101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)