Provider Demographics
NPI:1134504301
Name:BRAVERMAN, JEREMY (LMT, LAC, MAC)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:BRAVERMAN
Suffix:
Gender:M
Credentials:LMT, LAC, MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 BUCHANAN AVE
Mailing Address - Street 2:APT. B
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21211-1216
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3401 CHESTNUT AVE STE R
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21211-2585
Practice Address - Country:US
Practice Address - Phone:720-201-4729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-29
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM04891225700000X
MDUI02152171100000X
DCMT1356225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist