Provider Demographics
NPI:1528594496
Name:BRACKE, CHRISTINA
Entity Type:Individual
Prefix:MISS
First Name:CHRISTINA
Middle Name:
Last Name:BRACKE
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 1:337 WASHINGTON AVE N APT 529
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55401-2745
Mailing Address - Country:US
Mailing Address - Phone:501-922-7780
Mailing Address - Fax:
Practice Address - Street 1:337 WASHINGTON AVE N APT 529
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55401-2745
Practice Address - Country:US
Practice Address - Phone:501-922-7780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9852235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist