Provider Demographics
NPI:1073676102
Name:BRADEN, STACI A (PT)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:A
Last Name:BRADEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10024 CADE TRL
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-6648
Mailing Address - Country:US
Mailing Address - Phone:682-551-9244
Mailing Address - Fax:
Practice Address - Street 1:2421 IRA E WOODS AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-3906
Practice Address - Country:US
Practice Address - Phone:817-410-7773
Practice Address - Fax:817-421-5440
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1148280225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8T7054OtherBCBS PROVIDER #
TX1148280OtherSTATE LICENSE