Provider Demographics
NPI:1881711059
Name:BREAULT, RENEE A (ATC)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:A
Last Name:BREAULT
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 PEACHTREE LN
Mailing Address - Street 2:APT. 1
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05446
Mailing Address - Country:US
Mailing Address - Phone:802-373-5270
Mailing Address - Fax:
Practice Address - Street 1:JOHNSON STATE COLLEGE
Practice Address - Street 2:337 COLLEGE HILL
Practice Address - City:JOHNSON
Practice Address - State:VT
Practice Address - Zip Code:05656
Practice Address - Country:US
Practice Address - Phone:802-635-1487
Practice Address - Fax:802-635-1497
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT10400000932255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer