Provider Demographics
NPI:1477750354
Name:BRADEN, LATREVA JANICE
Entity Type:Individual
Prefix:
First Name:LATREVA
Middle Name:JANICE
Last Name:BRADEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LATREVA
Other - Middle Name:JANICE
Other - Last Name:MONTGOMERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9808 VENICE BLVD STE 700
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-6824
Mailing Address - Country:US
Mailing Address - Phone:310-945-3350
Mailing Address - Fax:
Practice Address - Street 1:923 S CATALINA AVE
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-4718
Practice Address - Country:US
Practice Address - Phone:310-945-3350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker