Provider Demographics
NPI:1760008957
Name:PAINE, BRAEDEN TYLER
Entity Type:Individual
Prefix:
First Name:BRAEDEN
Middle Name:TYLER
Last Name:PAINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1219 E BELLOWS ST APT I1
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-3649
Mailing Address - Country:US
Mailing Address - Phone:540-426-9933
Mailing Address - Fax:
Practice Address - Street 1:623 W WARWICK DR STE 2
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:MI
Practice Address - Zip Code:48801-1177
Practice Address - Country:US
Practice Address - Phone:989-285-1490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-23
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician