Provider Demographics
NPI:1548787443
Name:BRAKHAGE, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BRAKHAGE
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:PO BOX 34834
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78265-4834
Mailing Address - Country:US
Mailing Address - Phone:210-757-3150
Mailing Address - Fax:800-508-0086
Practice Address - Street 1:19115 FM 2252 STE 4
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78266-2578
Practice Address - Country:US
Practice Address - Phone:210-757-3150
Practice Address - Fax:800-508-0086
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-23
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX77926101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional