Provider Demographics
NPI:1093101982
Name:BREAULT, DAVID LEE (LPC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LEE
Last Name:BREAULT
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:39819-4465
Mailing Address - Country:US
Mailing Address - Phone:229-248-2683
Mailing Address - Fax:
Practice Address - Street 1:1005 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:39819-4465
Practice Address - Country:US
Practice Address - Phone:229-248-2683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-08
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007527101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health