Provider Demographics
NPI:1205912086
Name:BRAKE, RICHARD G (PSYD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:G
Last Name:BRAKE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15321 SAN PEDRO AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-3712
Mailing Address - Country:US
Mailing Address - Phone:210-587-6177
Mailing Address - Fax:210-587-6178
Practice Address - Street 1:15321 SAN PEDRO AVE STE 102
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-3712
Practice Address - Country:US
Practice Address - Phone:210-587-6177
Practice Address - Fax:210-587-6178
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14197103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX160425801Medicaid
TX160425801Medicaid