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General NPI Number Information
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NPI Number | 1053840975
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Entity Type | Individual
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Provider Name | BRADEN ALEC SULLIVAN N/A
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Gender | Male
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Dates
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Enumeration Date | 06/05/2017
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Last Update Date | 06/26/2018
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Provider Practice Location Address
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Address Line | 2258 N LAKEWAY CIR
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City | WICHITA
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State | KS
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Zip | 67205
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Country | US
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Telephone | 316-945-7117
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Fax | 316-945-7447
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Provider Business Mailing Address
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Address Line | 3223 N OLIVER ST
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City | WICHITA
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State | KS
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Zip | 67220-2106
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Country | US
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Telephone | 316-558-3410
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Fax | 316-267-5444
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 385HR2060X
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Taxonomy Name | Child Intellectual and/or Developmental Disabilities Respite Care
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License Number |
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License Number State | KS
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Taxonomy #2
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Taxonomy Code | 106E00000X
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Taxonomy Name | Assistant Behavior Analyst
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License Number |
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License Number State |
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