Provider Demographics
NPI:1902207012
Name:BREAULT, TAMMY
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:BREAULT
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 1:363 PETERSON DR
Mailing Address - Street 2:
Mailing Address - City:DRESSER
Mailing Address - State:WI
Mailing Address - Zip Code:54009-9005
Mailing Address - Country:US
Mailing Address - Phone:715-755-4684
Mailing Address - Fax:
Practice Address - Street 1:133 N MONROE
Practice Address - Street 2:
Practice Address - City:SAINT CROIX FALLS
Practice Address - State:WI
Practice Address - Zip Code:54024-9500
Practice Address - Country:US
Practice Address - Phone:651-795-9777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-08
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2257-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional