Provider Demographics
NPI:1215763388
Name:BRAKER, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BRAKER
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 1:3360 GATEWAY RD STE 200
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-5115
Mailing Address - Country:US
Mailing Address - Phone:262-923-7101
Mailing Address - Fax:262-923-7178
Practice Address - Street 1:3360 GATEWAY RD STE 200
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-5115
Practice Address - Country:US
Practice Address - Phone:262-923-7101
Practice Address - Fax:262-923-7178
Is Sole Proprietor?:No
Enumeration Date:2024-09-13
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist