Provider Demographics
NPI:1265926695
Name:BRAHA, ERIC (LMT)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:BRAHA
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6975 E PRINCESS DR APT 2059
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85054-4220
Mailing Address - Country:US
Mailing Address - Phone:602-370-7336
Mailing Address - Fax:
Practice Address - Street 1:2101 E BROADWAY RD STE 21
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-1735
Practice Address - Country:US
Practice Address - Phone:602-370-7336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-19
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-02202P225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist