Provider Demographics
NPI:1417553694
Name:BRASHARES, RAEANNA
Entity Type:Individual
Prefix:
First Name:RAEANNA
Middle Name:
Last Name:BRASHARES
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 1:7242 W JAMES LN
Mailing Address - Street 2:
Mailing Address - City:MONEE
Mailing Address - State:IL
Mailing Address - Zip Code:60449-8811
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4440 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2600
Practice Address - Country:US
Practice Address - Phone:708-684-1323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-11
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146011529235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist