Provider Demographics
NPI:1669656245
Name:BRAAKSMA, EUGENE F (PHD)
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:F
Last Name:BRAAKSMA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 W HISTORIC MITCHELL ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-3533
Mailing Address - Country:US
Mailing Address - Phone:414-383-9526
Mailing Address - Fax:414-671-6606
Practice Address - Street 1:930 W HISTORIC MITCHELL ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-3533
Practice Address - Country:US
Practice Address - Phone:414-383-9526
Practice Address - Fax:414-671-6606
Is Sole Proprietor?:No
Enumeration Date:2007-12-19
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1236-057101YM0800X
WI1236103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health