Provider Demographics
NPI:1801266440
Name:BRUNEAU, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BRUNEAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 WILLARD AVE
Mailing Address - Street 2:BLDG. 1, SUITE 1-D
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-2650
Mailing Address - Country:US
Mailing Address - Phone:860-665-8265
Mailing Address - Fax:860-665-8310
Practice Address - Street 1:505 WILLARD AVE
Practice Address - Street 2:BLDG. 1, SUITE 1-D
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-2650
Practice Address - Country:US
Practice Address - Phone:860-665-8265
Practice Address - Fax:860-665-8310
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-25
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT10239225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist