Provider Demographics
NPI:1750824900
Name:BRAXTON, RUBY
Entity Type:Individual
Prefix:
First Name:RUBY
Middle Name:
Last Name:BRAXTON
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 1:936 E. CARROLL STREET
Mailing Address - Street 2:
Mailing Address - City:COUSHATTA
Mailing Address - State:LA
Mailing Address - Zip Code:71019
Mailing Address - Country:US
Mailing Address - Phone:318-626-5462
Mailing Address - Fax:318-626-5562
Practice Address - Street 1:936 E. CARROLL STREET
Practice Address - Street 2:
Practice Address - City:COUSHATTA
Practice Address - State:LA
Practice Address - Zip Code:71019
Practice Address - Country:US
Practice Address - Phone:318-626-5462
Practice Address - Fax:318-626-5562
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health