Provider Demographics
NPI:1437618832
Name:BRISEBOIS-TETRAULT, CHERIE RENEE (RE LE)
Entity Type:Individual
Prefix:
First Name:CHERIE
Middle Name:RENEE
Last Name:BRISEBOIS-TETRAULT
Suffix:
Gender:F
Credentials:RE LE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 GRANBY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH HADLEY
Mailing Address - State:MA
Mailing Address - Zip Code:01075-2145
Mailing Address - Country:US
Mailing Address - Phone:413-733-2499
Mailing Address - Fax:413-255-0443
Practice Address - Street 1:62 WESTFIELD ST STE 2
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089-2539
Practice Address - Country:US
Practice Address - Phone:413-733-2499
Practice Address - Fax:413-255-0443
Is Sole Proprietor?:No
Enumeration Date:2019-03-15
Last Update Date:2021-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1702246Z00000X
MAL-30246Z00000X
CT547246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1702OtherELECTROLOGIST LICENSE NUMBER
CT547OtherELECTROLOGIST LICENSE NUMBER
MAL-30OtherLASER ELECTROLYSIS LICENSE