Provider Demographics
NPI:1710400833
Name:LIRETTE, BREALON MICHAEL (PMHNP)
Entity Type:Individual
Prefix:MR
First Name:BREALON
Middle Name:MICHAEL
Last Name:LIRETTE
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:MR
Other - First Name:BREALON
Other - Middle Name:MICHAEL
Other - Last Name:LIRETTE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PMHNP
Mailing Address - Street 1:242 WOODWIND DR
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-3996
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5599 HIGHWAY 311
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-2866
Practice Address - Country:US
Practice Address - Phone:985-857-3615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-20
Last Update Date:2017-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP09510363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health