Healthcare Provider Details

I. General information

NPI: 1104204619
Provider Name (Legal Business Name): RICHARD BREAULT LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2015
Last Update Date: 05/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 ELM ST SUITE 3B
WORCESTER MA
01609-2574
US

IV. Provider business mailing address

50 ELM ST SUITE 3B
WORCESTER MA
01609-2574
US

V. Phone/Fax

Practice location:
  • Phone: 508-755-0436
  • Fax:
Mailing address:
  • Phone: 508-755-0436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1017552
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: