Provider Demographics
NPI:1003021106
Name:BRADDOCK, SUZIE DEANN (LPC)
Entity Type:Individual
Prefix:MS
First Name:SUZIE
Middle Name:DEANN
Last Name:BRADDOCK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 N MAIN ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-1348
Mailing Address - Country:US
Mailing Address - Phone:580-471-9948
Mailing Address - Fax:
Practice Address - Street 1:3000 N MAIN ST
Practice Address - Street 2:SUITE C
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-1348
Practice Address - Country:US
Practice Address - Phone:580-471-9948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2945101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional