Provider Demographics
NPI:1427054212
Name:BRAZEAL, TAMMY JO (PHD)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:JO
Last Name:BRAZEAL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6363 SOUTH FARM ROAD 35
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MO
Mailing Address - Zip Code:65610-9407
Mailing Address - Country:US
Mailing Address - Phone:417-766-6996
Mailing Address - Fax:
Practice Address - Street 1:102 LILLIAN
Practice Address - Street 2:
Practice Address - City:CRANE
Practice Address - State:MO
Practice Address - Zip Code:65633-9103
Practice Address - Country:US
Practice Address - Phone:417-766-6996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1999139460103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO494806516Medicaid