Healthcare Provider Details

I. General information

NPI: 1316056518
Provider Name (Legal Business Name): RONALD WALTER BRAASCH JR. PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 GREEN BAY ROAD BUILDING 11
NORTH CHICAGO IL
60064
US

IV. Provider business mailing address

301 N MAPLE AVE
ELMHURST IL
60126-2332
US

V. Phone/Fax

Practice location:
  • Phone: 847-688-1900
  • Fax: 224-610-3778
Mailing address:
  • Phone: 847-688-1900
  • Fax: 224-610-3778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: