Provider Demographics
NPI:1699864918
Name:BREAULT, CANDACE T (LCSW)
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:T
Last Name:BREAULT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 HALL AVE
Mailing Address - Street 2:MARINETTE COUNTY HEALTH AND HUMAN SERVICES STE A
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143
Mailing Address - Country:US
Mailing Address - Phone:715-732-7760
Mailing Address - Fax:715-732-7711
Practice Address - Street 1:2500 HALL AVE
Practice Address - Street 2:MARINETTE COUNTY HEALTH AND HUMAN SERVICES STE A
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143
Practice Address - Country:US
Practice Address - Phone:715-732-7760
Practice Address - Fax:715-732-7711
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33461231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3346123OtherLICENSE
WI39638400Medicaid