Provider Demographics
NPI:1295826980
Name:BRACKE, PAUL E
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:E
Last Name:BRACKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6239 COLLEGE AVENUE
Mailing Address - Street 2:STE 204
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94618-1329
Mailing Address - Country:US
Mailing Address - Phone:510-287-9190
Mailing Address - Fax:
Practice Address - Street 1:6239 COLLEGE AVENUE
Practice Address - Street 2:STE 204
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94618-1329
Practice Address - Country:US
Practice Address - Phone:510-287-9190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10435103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL104351Medicare ID - Type Unspecified