Healthcare Provider Details

I. General information

NPI: 1609467802
Provider Name (Legal Business Name): MIA YADIRA BREULER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2021
Last Update Date: 01/30/2021
Certification Date: 01/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 VISTA TER
NEW HAVEN CT
06515-2472
US

IV. Provider business mailing address

110 VISTA TER
NEW HAVEN CT
06515-2472
US

V. Phone/Fax

Practice location:
  • Phone: 203-464-2846
  • Fax:
Mailing address:
  • Phone: 203-464-2846
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number7903092231
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number003702
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: