Healthcare Provider Details

I. General information

NPI: 1437618832
Provider Name (Legal Business Name): CHERIE RENEE BRISEBOIS-TETRAULT RE LE CLT LLT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2019
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 GRANBY RD
SOUTH HADLEY MA
01075-2145
US

IV. Provider business mailing address

460 GRANBY RD
SOUTH HADLEY MA
01075-2145
US

V. Phone/Fax

Practice location:
  • Phone: 413-733-2499
  • Fax: 413-255-0443
Mailing address:
  • Phone: 413-733-2499
  • Fax: 413-255-0443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number1702
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License NumberL-30
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number547
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: