Provider Demographics
NPI:1316150980
Name:BRAATEN, ALLAN P (MA)
Entity type:Individual
Prefix:
First Name:ALLAN
Middle Name:P
Last Name:BRAATEN
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:THERMOPOLIS
Mailing Address - State:WY
Mailing Address - Zip Code:82443-2634
Mailing Address - Country:US
Mailing Address - Phone:307-864-3138
Mailing Address - Fax:307-864-3139
Practice Address - Street 1:121 S 4TH ST
Practice Address - Street 2:
Practice Address - City:THERMOPOLIS
Practice Address - State:WY
Practice Address - Zip Code:82443-2634
Practice Address - Country:US
Practice Address - Phone:307-864-3138
Practice Address - Fax:307-864-3139
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLPC # 496101YP2500X
MNLICSW # 2661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY132371700Medicaid
WY108969204Medicaid
WY132371700Medicaid
WY108969201Medicaid