Provider Demographics
NPI:1972171197
Name:BRAKENWAGEN, COLEEN E
Entity Type:Individual
Prefix:
First Name:COLEEN
Middle Name:E
Last Name:BRAKENWAGEN
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 1:166 HALLS HILL RD
Mailing Address - Street 2:
Mailing Address - City:DANIELSON
Mailing Address - State:CT
Mailing Address - Zip Code:06239-3319
Mailing Address - Country:US
Mailing Address - Phone:860-608-8088
Mailing Address - Fax:
Practice Address - Street 1:62 PROVIDENCE PIKE STE E
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-2415
Practice Address - Country:US
Practice Address - Phone:888-805-0759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst