Provider Demographics
NPI:1285021105
Name:BRAUDT, KIRSTEN ELISSA
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:ELISSA
Last Name:BRAUDT
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 1:12450 SW KNOLL DR
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8266
Mailing Address - Country:US
Mailing Address - Phone:503-730-8662
Mailing Address - Fax:
Practice Address - Street 1:5200 SW MACADAM AVE
Practice Address - Street 2:SUITE 580
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-6103
Practice Address - Country:US
Practice Address - Phone:503-231-7854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-17
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health