Provider Demographics
NPI:1275691776
Name:BRAATEN, WENDY FAITH (PT)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:FAITH
Last Name:BRAATEN
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 1:2850 N 24TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-1004
Mailing Address - Country:US
Mailing Address - Phone:602-633-8686
Mailing Address - Fax:602-633-8786
Practice Address - Street 1:2850 N 24TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-1004
Practice Address - Country:US
Practice Address - Phone:602-633-8686
Practice Address - Fax:602-633-8786
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5047225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ576499Medicaid
AZ5047OtherSTATE LICENSE
AZ5047OtherSTATE LICENSE