Healthcare Provider Details

I. General information

NPI: 1740197680
Provider Name (Legal Business Name): LAUREN BRADDOCK-MOFFETT ED.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4323 GLENWAY AVE
CINCINNATI OH
45205-1507
US

IV. Provider business mailing address

4323 GLENWAY AVE
CINCINNATI OH
45205-1507
US

V. Phone/Fax

Practice location:
  • Phone: 513-363-9813
  • Fax: 513-363-9820
Mailing address:
  • Phone: 513-363-9813
  • Fax: 513-363-9820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberLSP.02232
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: