Provider Demographics
NPI:1871004887
Name:BRAZZLETON, LACRETIA
Entity Type:Individual
Prefix:
First Name:LACRETIA
Middle Name:
Last Name:BRAZZLETON
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 1:17746 OAK PARK AVE
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-3936
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14447 S BENSLEY AVE
Practice Address - Street 2:
Practice Address - City:BURNHAM
Practice Address - State:IL
Practice Address - Zip Code:60633-2224
Practice Address - Country:US
Practice Address - Phone:708-862-0212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-17
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator