Healthcare Provider Details

I. General information

NPI: 1447467311
Provider Name (Legal Business Name): BARBRA B BRAITHWAITE LLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 WEST U.S. 2
WAKEFIELD MI
49968
US

IV. Provider business mailing address

27790 WEST M-64
ONTONAGON MI
49953
US

V. Phone/Fax

Practice location:
  • Phone: 906-229-6120
  • Fax: 906-229-6191
Mailing address:
  • Phone: 906-884-4474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberL964866
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: