Provider Demographics
NPI:1376096875
Name:KINGSFORD, BRAIDEN (DPT)
Entity Type:Individual
Prefix:DR
First Name:BRAIDEN
Middle Name:
Last Name:KINGSFORD
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 72
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0072
Mailing Address - Country:US
Mailing Address - Phone:509-598-9402
Mailing Address - Fax:
Practice Address - Street 1:21651 E COUNTRY VISTA DR
Practice Address - Street 2:
Practice Address - City:LIBERTY LAKE
Practice Address - State:WA
Practice Address - Zip Code:99019-7708
Practice Address - Country:US
Practice Address - Phone:509-598-9402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-01
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT5553225100000X
WAPT60645217225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist