Provider Demographics
NPI:1518168939
Name:BRADDICK, PREMADONNA (MA, LPC)
Entity Type:Individual
Prefix:MRS
First Name:PREMADONNA
Middle Name:
Last Name:BRADDICK
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8086 S YALE AVE # 236
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-9003
Mailing Address - Country:US
Mailing Address - Phone:918-892-1797
Mailing Address - Fax:
Practice Address - Street 1:5424 NORTH MADISON AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74126
Practice Address - Country:US
Practice Address - Phone:918-892-1797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor