Healthcare Provider Details

I. General information

NPI: 1871744508
Provider Name (Legal Business Name): THERESE A BRAASCH ACUPUNCTURIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2008
Last Update Date: 02/06/2020
Certification Date: 02/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E DUPONT RD
FORT WAYNE IN
46825-2055
US

IV. Provider business mailing address

6821 WOODCREST DR.
FORT WAYNE IN
46815
US

V. Phone/Fax

Practice location:
  • Phone: 260-413-7160
  • Fax:
Mailing address:
  • Phone: 260-485-1879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number84000105A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number26017081A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: