Provider Demographics
NPI:1366105397
Name:BREAULT, DENISE NICOLE (OTA)
Entity type:Individual
Prefix:MS
First Name:DENISE
Middle Name:NICOLE
Last Name:BREAULT
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3202 ROUTE 145 # 2
Mailing Address - Street 2:
Mailing Address - City:PRESTON HOLLOW
Mailing Address - State:NY
Mailing Address - Zip Code:12469-1806
Mailing Address - Country:US
Mailing Address - Phone:518-390-0045
Mailing Address - Fax:
Practice Address - Street 1:38 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:CATSKILL
Practice Address - State:NY
Practice Address - Zip Code:12414-1514
Practice Address - Country:US
Practice Address - Phone:518-943-5701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-17
Last Update Date:2021-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007951-01224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY007951-01Medicaid