MEDICARE: BRAKEN GROUP, LLP

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	261QM0850X	Adult Mental Health Clinic/Center
2	261QA0600X	Adult Day Care Clinic/Center

General Provider Information

NPI Number	:	1952805962
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRAKEN GROUP, LLP

Provider Business Mailing Address
First Line	:	6431 ROSALIE DR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75236-2232
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6431 ROSALIE DR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75236
Country	:	US
Telephone Number	:	337-304-2793
Fax Number	:

Authorized Official
Title or Position	:	PARTNER/ADMINISTRATOR
Name	:	JUSTIN CORMIER
Credential	:
Telephone Number	:	214-729-2679

Provider Enumeration Date	:	03/23/2018
Last Update Date	:	05/15/2018

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