Provider Demographics
NPI:1124040415
Name:BRAUTIGAM, PAUL ALLEN (LPC, NCC)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:ALLEN
Last Name:BRAUTIGAM
Suffix:
Gender:M
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 HICKORY HILL DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-1948
Mailing Address - Country:US
Mailing Address - Phone:636-379-0294
Mailing Address - Fax:
Practice Address - Street 1:501 1ST CAPITOL DR
Practice Address - Street 2:SUITE 4
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-2768
Practice Address - Country:US
Practice Address - Phone:636-946-1500
Practice Address - Fax:636-946-1516
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001031938101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional