Provider Demographics
NPI:1053700278
Name:HARRIS, BRADEN
Entity type:Individual
Prefix:
First Name:BRADEN
Middle Name:
Last Name:HARRIS
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 1:10822 VICTORY BLVD APT 18
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-3866
Mailing Address - Country:US
Mailing Address - Phone:310-270-1820
Mailing Address - Fax:
Practice Address - Street 1:10822 VICTORY BLVD APT 18
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-3866
Practice Address - Country:US
Practice Address - Phone:310-270-1820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-12
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CATA 6590225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant