Provider Demographics
NPI:1275921629
Name:PASSALACQUA, BREANNE TERESA (MA,TLLP)
Entity Type:Individual
Prefix:MRS
First Name:BREANNE
Middle Name:TERESA
Last Name:PASSALACQUA
Suffix:
Gender:F
Credentials:MA,TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10291 FOLEY RD
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-9250
Mailing Address - Country:US
Mailing Address - Phone:810-597-7293
Mailing Address - Fax:
Practice Address - Street 1:4400 S SAGINAW ST
Practice Address - Street 2:SUIT 1460
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-2645
Practice Address - Country:US
Practice Address - Phone:810-237-0799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-07
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016145171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator