Provider Demographics
NPI:1982462750
Name:BRACKENBURY, EVAN TODD
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:TODD
Last Name:BRACKENBURY
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 1:11114 W ARICA RD
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85193-9033
Mailing Address - Country:US
Mailing Address - Phone:520-634-8601
Mailing Address - Fax:
Practice Address - Street 1:8811 S TACOMA WAY STE 204&206
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98499-4595
Practice Address - Country:US
Practice Address - Phone:425-217-1140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-07
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician