Provider Demographics
NPI:1033455076
Name:BRATHOLT, DOUGLAS ROBERT (LCSW)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:ROBERT
Last Name:BRATHOLT
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 VETERANS WAY
Mailing Address - Street 2:VETERANS HEALTH ADMINISTRATION- VA OPC HCHV
Mailing Address - City:VIERA
Mailing Address - State:FL
Mailing Address - Zip Code:32940
Mailing Address - Country:US
Mailing Address - Phone:321-637-3788
Mailing Address - Fax:
Practice Address - Street 1:2900 VETERANS WAY
Practice Address - Street 2:
Practice Address - City:VIERA
Practice Address - State:FL
Practice Address - Zip Code:32940-8007
Practice Address - Country:US
Practice Address - Phone:321-637-3788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-19
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW105861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical