Provider Demographics
NPI:1780040543
Name:BRACE, CALVIN JAMES (SAC-IT)
Entity Type:Individual
Prefix:
First Name:CALVIN
Middle Name:JAMES
Last Name:BRACE
Suffix:
Gender:M
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 E BADGER RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53713-2708
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:151 E BADGER RD
Practice Address - Street 2:SUITE A
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53713-2708
Practice Address - Country:US
Practice Address - Phone:608-250-2512
Practice Address - Fax:608-250-2516
Is Sole Proprietor?:No
Enumeration Date:2016-01-11
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17156-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1629282470OtherEMPLOYER IDENTIFICATION