Provider Demographics
NPI:1083367056
Name:LAFOREST, BREAH
Entity Type:Individual
Prefix:
First Name:BREAH
Middle Name:
Last Name:LAFOREST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NH
Mailing Address - Zip Code:03824-2512
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 MAIN ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NH
Practice Address - Zip Code:03824-2512
Practice Address - Country:US
Practice Address - Phone:603-862-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-31
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty