Provider Demographics
NPI:1639548720
Name:BRAZEAL, RAYMONDA
Entity Type:Individual
Prefix:
First Name:RAYMONDA
Middle Name:
Last Name:BRAZEAL
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 1:2200 VALLEY VIEW PKWY
Mailing Address - Street 2:APT 4134
Mailing Address - City:EL DORADO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:95762-5567
Mailing Address - Country:US
Mailing Address - Phone:530-333-7647
Mailing Address - Fax:
Practice Address - Street 1:5607 MOUNT MURPHY RD
Practice Address - Street 2:
Practice Address - City:GARDEN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95633
Practice Address - Country:US
Practice Address - Phone:530-333-9460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-18
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1199280415101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)