Provider Demographics
NPI:1629775465
Name:DIEBOLD, BRADEN
Entity Type:Individual
Prefix:
First Name:BRADEN
Middle Name:
Last Name:DIEBOLD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 PARK ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55103-1846
Mailing Address - Country:US
Mailing Address - Phone:701-871-0347
Mailing Address - Fax:
Practice Address - Street 1:731 BIELENBERG DR STE 102-104
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-1700
Practice Address - Country:US
Practice Address - Phone:612-445-8326
Practice Address - Fax:612-445-8325
Is Sole Proprietor?:No
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician