Provider Demographics
NPI:1780221119
Name:BREAULT, ANDREW JAY (LMSW)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:JAY
Last Name:BREAULT
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:ME
Mailing Address - Zip Code:04937-1528
Mailing Address - Country:US
Mailing Address - Phone:207-453-4500
Mailing Address - Fax:
Practice Address - Street 1:121 MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:ME
Practice Address - Zip Code:04937-1528
Practice Address - Country:US
Practice Address - Phone:207-453-4500
Practice Address - Fax:207-453-4502
Is Sole Proprietor?:No
Enumeration Date:2019-12-04
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC18240101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor