Provider Demographics
NPI:1366741126
Name:BRAINERD, ROBERT HENRY JR (LATC, CSCS)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:HENRY
Last Name:BRAINERD
Suffix:JR
Gender:M
Credentials:LATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 SAINT TEKAKWITHA DR
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-2456
Mailing Address - Country:US
Mailing Address - Phone:207-784-3477
Mailing Address - Fax:
Practice Address - Street 1:30 BELGRADE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-4095
Practice Address - Country:US
Practice Address - Phone:207-783-0018
Practice Address - Fax:207-783-0019
Is Sole Proprietor?:No
Enumeration Date:2011-03-19
Last Update Date:2011-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAT652255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer