Provider Demographics
NPI:1699947127
Name:BRADEN, ALICIA (LMP)
Entity type:Individual
Prefix:MRS
First Name:ALICIA
Middle Name:
Last Name:BRADEN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:MRS
Other - First Name:ALYSON
Other - Middle Name:
Other - Last Name:BRADEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMP
Mailing Address - Street 1:6694 PINE ST.
Mailing Address - Street 2:
Mailing Address - City:BONNERS FERRY
Mailing Address - State:ID
Mailing Address - Zip Code:83805-8513
Mailing Address - Country:US
Mailing Address - Phone:208-267-7869
Mailing Address - Fax:
Practice Address - Street 1:6606 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:BONNERS FERRY
Practice Address - State:ID
Practice Address - Zip Code:83805-8513
Practice Address - Country:US
Practice Address - Phone:208-290-7088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00011216172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist