Provider Demographics
NPI:1679105126
Name:KURZAWE-BREAULT, PHILOMENA (MA, TLLP, QBHP)
Entity type:Individual
Prefix:MRS
First Name:PHILOMENA
Middle Name:
Last Name:KURZAWE-BREAULT
Suffix:
Gender:F
Credentials:MA, TLLP, QBHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 KRAFFT RD
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-3565
Mailing Address - Country:US
Mailing Address - Phone:810-985-5125
Mailing Address - Fax:
Practice Address - Street 1:195 HURON BLVD
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:MI
Practice Address - Zip Code:48040-1421
Practice Address - Country:US
Practice Address - Phone:224-498-9401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-12
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362010031103TC0700X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical