Healthcare Provider Details

I. General information

NPI: 1962919035
Provider Name (Legal Business Name): CARI S. BRADDOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

628 LAKE ST NE
WISE VA
24293-7919
US

IV. Provider business mailing address

628 LAKE ST NE
WISE VA
24293-7919
US

V. Phone/Fax

Practice location:
  • Phone: 276-328-8017
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberPGP-0646591
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: