Provider Demographics
NPI:1316461072
Name:BRATHWAITE, RENE GREGSTON (LPCMH, ICCDP-D, NCC)
Entity type:Individual
Prefix:MR
First Name:RENE
Middle Name:GREGSTON
Last Name:BRATHWAITE
Suffix:
Gender:M
Credentials:LPCMH, ICCDP-D, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 SHETLAND DR
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:DE
Mailing Address - Zip Code:19720-8832
Mailing Address - Country:US
Mailing Address - Phone:917-617-7839
Mailing Address - Fax:
Practice Address - Street 1:262 CHAPMAN RD STE 203
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19702-5442
Practice Address - Country:US
Practice Address - Phone:302-689-3562
Practice Address - Fax:302-294-1757
Is Sole Proprietor?:No
Enumeration Date:2017-08-02
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEPC-0000813101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty