Provider Demographics
NPI:1578334884
Name:BRADDOCK, ANNETTE RENA
Entity type:Individual
Prefix:
First Name:ANNETTE
Middle Name:RENA
Last Name:BRADDOCK
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 1:14501 NW 16TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33167-1010
Mailing Address - Country:US
Mailing Address - Phone:305-215-6726
Mailing Address - Fax:
Practice Address - Street 1:850 NW FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-1019
Practice Address - Country:US
Practice Address - Phone:954-579-7973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-15
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB946996106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician