Provider Demographics
NPI:1306086525
Name:BRAYDEN, AMADEA I (LICAC)
Entity type:Individual
Prefix:
First Name:AMADEA
Middle Name:I
Last Name:BRAYDEN
Suffix:
Gender:F
Credentials:LICAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 S JOHNSON ST STE 207
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-3259
Mailing Address - Country:US
Mailing Address - Phone:312-523-4675
Mailing Address - Fax:
Practice Address - Street 1:110 S JOHNSON ST STE 207
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-3259
Practice Address - Country:US
Practice Address - Phone:312-523-4675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-27
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.000857171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist