Provider Demographics
NPI:1689810970
Name:BRASWELL, KATINA
Entity Type:Individual
Prefix:
First Name:KATINA
Middle Name:
Last Name:BRASWELL
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 1:3220 PRIDWEN CIR APT 304
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-1282
Mailing Address - Country:US
Mailing Address - Phone:804-221-7286
Mailing Address - Fax:
Practice Address - Street 1:10 PARKER LN
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-7903
Practice Address - Country:US
Practice Address - Phone:910-295-3133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-17
Last Update Date:2009-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0038301041C0700X
NCC0062711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC562033116OtherTRICARE
NC3403400Medicaid