MEDICARE: MAIA NYSTRUM BRADEN M.S., CCC-SLP

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	3198-154	WI

General Provider Information

NPI Number	:	1629268420
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAIA NYSTRUM BRADEN M.S., CCC-SLP

Provider Business Mailing Address
First Line	:	1675 HIGHLAND AVE
Second Line	:	MAILCODE C225
City	:	MADISON
State	:	WI
Zip	:	53792-0002
Country	:	US
Telephone Number	:	608-262-3695
Fax Number	:	608-265-7004

Provider Business Practice Location Address
First Line	:	1675 HIGHLAND AVE
Second Line	:	MAILCODE C225
City	:	MADISON
State	:	WI
Zip	:	53792-0002
Country	:	US
Telephone Number	:	608-262-3695
Fax Number	:	608-265-7004

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

Provider Enumeration Date	:	07/27/2007
Last Update Date	:	01/11/2021

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Directions to “ MAIA NYSTRUM BRADEN M.S., CCC-SLP” Practice Location

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