Provider Demographics
NPI:1215542055
Name:BRAXTON, MERCEDES
Entity Type:Individual
Prefix:
First Name:MERCEDES
Middle Name:
Last Name:BRAXTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 BAYWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-3186
Mailing Address - Country:US
Mailing Address - Phone:708-574-5442
Mailing Address - Fax:
Practice Address - Street 1:2130 KINGSTON CT SE STE E
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8952
Practice Address - Country:US
Practice Address - Phone:708-574-5442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC011704101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty