MEDICARE: ANTIGONE BRADDOCK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	34156	CA

General Provider Information

NPI Number	:	1568307411
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTIGONE BRADDOCK

Provider Business Mailing Address
First Line	:	1017 N LAKE ST
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91502-1625
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	501 E ACACIA AVE
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91205-2823
Country	:	US
Telephone Number	:	818-246-2421
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/20/2026
Last Update Date	:	04/20/2026

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Directions to “ ANTIGONE BRADDOCK ” Practice Location

Language	Start Address	Practice Location

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