Provider Demographics
NPI:1013290915
Name:BRETON, LISA MICHELE (PTA, LAC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELE
Last Name:BRETON
Suffix:
Gender:F
Credentials:PTA, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 RIVER ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-3315
Mailing Address - Country:US
Mailing Address - Phone:203-442-6297
Mailing Address - Fax:
Practice Address - Street 1:35 BUNKER HILL RD
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:CT
Practice Address - Zip Code:06795-3304
Practice Address - Country:US
Practice Address - Phone:860-274-5429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-27
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000064225200000X
CT000860171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No171100000XOther Service ProvidersAcupuncturist