Provider Demographics
NPI:1437542271
Name:BRUNELLE, DEIDRE
Entity Type:Individual
Prefix:
First Name:DEIDRE
Middle Name:
Last Name:BRUNELLE
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 1:417 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01104-3736
Mailing Address - Country:US
Mailing Address - Phone:413-736-3668
Mailing Address - Fax:413-731-8651
Practice Address - Street 1:98 LOWER WESTFIELD RD.
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040
Practice Address - Country:US
Practice Address - Phone:413-584-6855
Practice Address - Fax:413-532-1846
Is Sole Proprietor?:No
Enumeration Date:2015-03-17
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10726101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health