Provider Demographics
NPI:1962649640
Name:BROUILLETTE, STACEY PATRICIA
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:PATRICIA
Last Name:BROUILLETTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:PATRICIA
Other - Last Name:AMARAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 POSA PL
Mailing Address - Street 2:
Mailing Address - City:DARTMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02747-2511
Mailing Address - Country:US
Mailing Address - Phone:508-996-3391
Mailing Address - Fax:508-996-3397
Practice Address - Street 1:1 POSA PL
Practice Address - Street 2:
Practice Address - City:DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747-2511
Practice Address - Country:US
Practice Address - Phone:508-996-3391
Practice Address - Fax:508-996-3397
Is Sole Proprietor?:No
Enumeration Date:2009-01-16
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5551171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator