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Individual
MARY ANN BREAULT
Active
Individual
MARY ANN BREAULT
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LPT
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
070009033
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
020654168
TAX ID
IL
01
—
070009033
STATE LISCENSE
IL
01
—
10132053
BCBS PROVIDER NUMBER
IL
Enumeration date
02/26/2007
Last updated
07/08/2007
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