Provider Demographics
NPI:1104204619
Name:BREAULT, RICHARD (LICSW)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:BREAULT
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 ELM ST
Mailing Address - Street 2:SUITE 3B
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01609-2574
Mailing Address - Country:US
Mailing Address - Phone:508-755-0436
Mailing Address - Fax:
Practice Address - Street 1:50 ELM ST
Practice Address - Street 2:SUITE 3B
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01609-2574
Practice Address - Country:US
Practice Address - Phone:508-755-0436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-16
Last Update Date:2015-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10175521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical