Provider Demographics
NPI:1326404732
Name:BRAXTON, FETIMA (MSW)
Entity type:Individual
Prefix:MS
First Name:FETIMA
Middle Name:
Last Name:BRAXTON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5927 LEE VISTA BLVD APT 102
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822-1512
Mailing Address - Country:US
Mailing Address - Phone:407-781-6193
Mailing Address - Fax:
Practice Address - Street 1:2479 ALOMA AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-2541
Practice Address - Country:US
Practice Address - Phone:407-781-6193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-14
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW103501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical