Provider Demographics
NPI:1689658072
Name:BRAXTON, LORETTA ELAINE (PHD)
Entity Type:Individual
Prefix:DR
First Name:LORETTA
Middle Name:ELAINE
Last Name:BRAXTON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 W NC HIGHWAY 54
Mailing Address - Street 2:STE 113
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-5577
Mailing Address - Country:US
Mailing Address - Phone:919-401-8090
Mailing Address - Fax:919-401-8091
Practice Address - Street 1:1415 W NC HIGHWAY 54
Practice Address - Street 2:STE 113
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-5577
Practice Address - Country:US
Practice Address - Phone:919-401-8090
Practice Address - Fax:919-401-8091
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1679103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000707Medicaid