Provider Demographics
NPI:1164522637
Name:BREAULT, ADRIEL JANEEN (LICAC)
Entity Type:Individual
Prefix:MS
First Name:ADRIEL
Middle Name:JANEEN
Last Name:BREAULT
Suffix:
Gender:F
Credentials:LICAC
Other - Prefix:MS
Other - First Name:ADRIEL
Other - Middle Name:JANEEN
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICAC
Mailing Address - Street 1:101 HEATH ST #3
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02145-1515
Mailing Address - Country:US
Mailing Address - Phone:617-628-1880
Mailing Address - Fax:
Practice Address - Street 1:50 BEHARRALL ST
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742
Practice Address - Country:US
Practice Address - Phone:617-785-5256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA226331171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7064KOtherEMPIRE BCBS