Provider Demographics
NPI:1275907545
Name:BRADEN-SHYES-KU, LAUREN ASHLEY
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:ASHLEY
Last Name:BRADEN-SHYES-KU
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 1:4080 LEMON ST # 3
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-3609
Mailing Address - Country:US
Mailing Address - Phone:951-955-3500
Mailing Address - Fax:
Practice Address - Street 1:4080 LEMON ST # 3
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-3609
Practice Address - Country:US
Practice Address - Phone:951-955-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-24
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA101YM0800X, 104100000X
CAASW101181101YM0800X
CA1084991041C0700X
CALCSW1084991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker