Provider Demographics
NPI:1629268420
Name:BRADEN, MAIA NYSTRUM (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MAIA
Middle Name:NYSTRUM
Last Name:BRADEN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 HIGHLAND AVE
Mailing Address - Street 2:MAILCODE C225
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53792-0002
Mailing Address - Country:US
Mailing Address - Phone:608-262-3695
Mailing Address - Fax:608-265-7004
Practice Address - Street 1:1675 HIGHLAND AVE
Practice Address - Street 2:MAILCODE C225
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53792-0002
Practice Address - Country:US
Practice Address - Phone:608-262-3695
Practice Address - Fax:608-265-7004
Is Sole Proprietor?:No
Enumeration Date:2007-07-27
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3198-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist