Provider Demographics
NPI:1922583236
Name:BRAULT, MARTIN (LADC)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:BRAULT
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 HOLLYHOCK RD FL 2
Mailing Address - Street 2:
Mailing Address - City:WILTON
Mailing Address - State:CT
Mailing Address - Zip Code:06897-4414
Mailing Address - Country:US
Mailing Address - Phone:203-761-9487
Mailing Address - Fax:203-761-9487
Practice Address - Street 1:6 HOLLYHOCK RD FL 2
Practice Address - Street 2:
Practice Address - City:WILTON
Practice Address - State:CT
Practice Address - Zip Code:06897-4414
Practice Address - Country:US
Practice Address - Phone:203-761-9487
Practice Address - Fax:203-761-9487
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-02
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000696101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty