Provider Demographics
NPI:1588980965
Name:BRAESE, ROBERT W (PHD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:W
Last Name:BRAESE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 NE 13TH ST
Mailing Address - Street 2:(183-K)
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-5007
Mailing Address - Country:US
Mailing Address - Phone:405-456-3295
Mailing Address - Fax:
Practice Address - Street 1:921 NE 13TH ST
Practice Address - Street 2:(183-K)
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5007
Practice Address - Country:US
Practice Address - Phone:405-456-3295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-11
Last Update Date:2010-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1873103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical