Provider Demographics
NPI:1760161137
Name:BRADEN, JOHN LOREN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:LOREN
Last Name:BRADEN
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 1:2514 ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405-3916
Mailing Address - Country:US
Mailing Address - Phone:262-995-3312
Mailing Address - Fax:
Practice Address - Street 1:13200 GLOBE DR STE 206
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53177-1615
Practice Address - Country:US
Practice Address - Phone:262-260-8451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-13
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2044225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant