1700992708 NPI number — RITA JEAN BRAFFORD LCSW, CADC-D

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700992708 NPI number — RITA JEAN BRAFFORD LCSW, CADC-D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRAFFORD
Provider First Name:
RITA
Provider Middle Name:
JEAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW, CADC-D
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700992708
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/29/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1230 CORPORATE CENTER DR
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
OCONOMOWOC
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53066-4883
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-542-3255
Provider Business Mailing Address Fax Number:
262-567-5451

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
888 THACKERAY TRL
Provider Second Line Business Practice Location Address:
105
Provider Business Practice Location Address City Name:
OCONOMOWOC
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53066-4342
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-542-3255
Provider Business Practice Location Address Fax Number:
262-567-5451
Provider Enumeration Date:
08/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  6612-123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 13350 . This is a "ALCOHOL & DRUG COUNSELOR" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 39788800 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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