Provider Demographics
NPI:1205123924
Name:BREAULT, CARRIE DALI (MS)
Entity type:Individual
Prefix:MS
First Name:CARRIE
Middle Name:DALI
Last Name:BREAULT
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2917 13TH ST W
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33971-5403
Mailing Address - Country:US
Mailing Address - Phone:239-369-3988
Mailing Address - Fax:
Practice Address - Street 1:2917 13TH ST W
Practice Address - Street 2:APT/SUITE
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33971-5403
Practice Address - Country:US
Practice Address - Phone:239-851-9625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-01
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health