Healthcare Provider Details

I. General information

NPI: 1275921629
Provider Name (Legal Business Name): BREANNE TERESA PASSALACQUA M.A.,TLLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2015
Last Update Date: 02/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 S SAGINAW ST SUIT 1460
FLINT MI
48507-2645
US

IV. Provider business mailing address

10291 FOLEY RD
FENTON MI
48430-9250
US

V. Phone/Fax

Practice location:
  • Phone: 810-237-0799
  • Fax:
Mailing address:
  • Phone: 810-597-7293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number6301016145
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: