Provider Demographics
NPI:1588174023
Name:BROUILLETTE, REBECCA (DC)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:BROUILLETTE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:BIDDEFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04005-2540
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:57 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-2540
Practice Address - Country:US
Practice Address - Phone:860-759-8848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-11
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECR2428111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor