Provider Demographics
NPI:1871204842
Name:IMMEKUS, BRAYDEN ERIC
Entity type:Individual
Prefix:
First Name:BRAYDEN
Middle Name:ERIC
Last Name:IMMEKUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:BRAYDEN
Other - Middle Name:ERIC ELLIS
Other - Last Name:ATKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:71566 FLORIDA DR
Mailing Address - Street 2:
Mailing Address - City:TWENTYNINE PALMS
Mailing Address - State:CA
Mailing Address - Zip Code:92277-4070
Mailing Address - Country:US
Mailing Address - Phone:360-823-9925
Mailing Address - Fax:
Practice Address - Street 1:71566 FLORIDA DR
Practice Address - Street 2:
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92277-4070
Practice Address - Country:US
Practice Address - Phone:360-823-9925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-09
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22-241528106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician