Provider Demographics
NPI:1992923676
Name:BREAULT, KATHLEEN (EDD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:BREAULT
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 WILDBROOK DR
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01543-1266
Mailing Address - Country:US
Mailing Address - Phone:508-886-4954
Mailing Address - Fax:
Practice Address - Street 1:100 SOUTH ST
Practice Address - Street 2:
Practice Address - City:SOUTHBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01550-4051
Practice Address - Country:US
Practice Address - Phone:508-799-3175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6036101Y00000X
MA884103T00000X
MA274592103TS0200X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Not Answered1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool