Provider Demographics
NPI:1851061766
Name:BRACCIANO, BLAIR
Entity Type:Individual
Prefix:
First Name:BLAIR
Middle Name:
Last Name:BRACCIANO
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 1:1739 E 23RD ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66046-5017
Mailing Address - Country:US
Mailing Address - Phone:785-830-8238
Mailing Address - Fax:785-830-8246
Practice Address - Street 1:1739 E 23RD ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66046-5017
Practice Address - Country:US
Practice Address - Phone:785-830-8238
Practice Address - Fax:785-830-8246
Is Sole Proprietor?:No
Enumeration Date:2021-09-14
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS03887101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health