Provider Demographics
NPI:1497880009
Name:BRAATZ, GORDON A (PHD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:A
Last Name:BRAATZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6566 FRANCE AVE S
Mailing Address - Street 2:PH1
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-1723
Mailing Address - Country:US
Mailing Address - Phone:952-925-4909
Mailing Address - Fax:
Practice Address - Street 1:6566 FRANCE AVE S
Practice Address - Street 2:PH1
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-1723
Practice Address - Country:US
Practice Address - Phone:952-925-4909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1737103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical