Provider Demographics
NPI:1215267968
Name:BRACEY, KIM (BS, MS)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:BRACEY
Suffix:
Gender:F
Credentials:BS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1359 SWEET ARROW LAKE RD
Mailing Address - Street 2:
Mailing Address - City:PINE GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:17963-9006
Mailing Address - Country:US
Mailing Address - Phone:610-987-8519
Mailing Address - Fax:
Practice Address - Street 1:1359 SWEET ARROW LAKE ROAD
Practice Address - Street 2:
Practice Address - City:PINE GROVE
Practice Address - State:PA
Practice Address - Zip Code:17963
Practice Address - Country:US
Practice Address - Phone:610-987-8519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-31
Last Update Date:2009-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA62171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator