Healthcare Provider Details

I. General information

NPI: 1386683647
Provider Name (Legal Business Name): MELISSA SMITH BRAXTON LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 05/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2860 HIGHWAY 71 SUITE A
MARIANNA FL
32446-1867
US

IV. Provider business mailing address

2860 HIGHWAY 71 STE A
MARIANNA FL
32446-1893
US

V. Phone/Fax

Practice location:
  • Phone: 850-573-1491
  • Fax: 850-482-0015
Mailing address:
  • Phone: 850-573-1491
  • Fax: 850-482-0015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH6772
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: