Provider Demographics
NPI:1649556341
Name:BRATHWAITE, VICTOR ANTHONY (MSW)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:ANTHONY
Last Name:BRATHWAITE
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:682 BLOOMFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095-2311
Mailing Address - Country:US
Mailing Address - Phone:860-882-2967
Mailing Address - Fax:
Practice Address - Street 1:682 BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06095-2311
Practice Address - Country:US
Practice Address - Phone:860-882-2967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-25
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care