1710400833 NPI number — MR. BREALON MICHAEL LIRETTE PMHNP

Table of content: MR. BREALON MICHAEL LIRETTE PMHNP (NPI 1710400833)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710400833 NPI number — MR. BREALON MICHAEL LIRETTE PMHNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIRETTE
Provider First Name:
BREALON
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PMHNP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LIRETTE
Provider Other First Name:
BREALON
Provider Other Middle Name:
MICHAEL
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PMHNP
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1710400833
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/20/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
242 WOODWIND DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUMA
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70360-3996
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5599 HIGHWAY 311
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOUMA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70360-2866
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-857-3615
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/20/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  AP09510 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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