Provider Demographics
NPI:1033818216
Name:BRAXTON, DA'JOUR (MED)
Entity Type:Individual
Prefix:
First Name:DA'JOUR
Middle Name:
Last Name:BRAXTON
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2053 GAUSE BLVD E STE 150
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-5451
Mailing Address - Country:US
Mailing Address - Phone:985-649-1001
Mailing Address - Fax:
Practice Address - Street 1:2053 GAUSE BLVD E STE 150
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-5451
Practice Address - Country:US
Practice Address - Phone:985-649-1001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-27
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA012531787171M00000X
LAPLC9610101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA012531787Medicaid