Provider Demographics
NPI:1619430956
Name:BREAULT, LAURA AUBREY I (BCBA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:AUBREY
Last Name:BREAULT
Suffix:I
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1449 37TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-4380
Mailing Address - Country:US
Mailing Address - Phone:718-215-5311
Mailing Address - Fax:718-865-5196
Practice Address - Street 1:1706 11TH AVE APT 3
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-1391
Practice Address - Country:US
Practice Address - Phone:917-826-5222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-12
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1-19-35347103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY630299660OtherMETROPLUS