Provider Demographics
NPI:1073722807
Name:BRAUN, DEIDRE KATHARINE (LAC)
Entity Type:Individual
Prefix:
First Name:DEIDRE
Middle Name:KATHARINE
Last Name:BRAUN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47875 CALEO BAY DR
Mailing Address - Street 2:A104
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-6386
Mailing Address - Country:US
Mailing Address - Phone:760-771-2332
Mailing Address - Fax:760-771-2316
Practice Address - Street 1:47875 CALEO BAY DR
Practice Address - Street 2:A104
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-6386
Practice Address - Country:US
Practice Address - Phone:760-771-2332
Practice Address - Fax:760-771-2316
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC5378171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA330924223OtherTAX ID