Provider Demographics
NPI:1629474341
Name:BRADDOCK, ALYSIA
Entity Type:Individual
Prefix:
First Name:ALYSIA
Middle Name:
Last Name:BRADDOCK
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 1:9441 LBJ FWY
Mailing Address - Street 2:SUITE 602
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-4545
Mailing Address - Country:US
Mailing Address - Phone:469-249-1882
Mailing Address - Fax:877-788-7505
Practice Address - Street 1:9441 LBJ FWY
Practice Address - Street 2:SUITE 602
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-4545
Practice Address - Country:US
Practice Address - Phone:469-249-1882
Practice Address - Fax:877-788-7505
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-06
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALR60273231227900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WALR60273231OtherRESPIRATORY CARE PRACTITIONER LICENSE