Healthcare Provider Details

I. General information

NPI: 1750791307
Provider Name (Legal Business Name): KOENRAAD VAN BRAECKEL PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2014
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3665 KEARNY VILLA RD
SAN DIEGO CA
92123-1953
US

IV. Provider business mailing address

3020 CHILDRENS WAY
SAN DIEGO CA
92123-4223
US

V. Phone/Fax

Practice location:
  • Phone: 858-966-5817
  • Fax:
Mailing address:
  • Phone: 858-966-5817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY31225
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number072303
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: