Provider Demographics
NPI:1902692882
Name:WOOTERS, BRAYTON
Entity type:Individual
Prefix:
First Name:BRAYTON
Middle Name:
Last Name:WOOTERS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4932 KEMPER AVE # 2W
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139-1125
Mailing Address - Country:US
Mailing Address - Phone:217-343-9390
Mailing Address - Fax:
Practice Address - Street 1:4932 KEMPER AVE # 2W
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63139-1125
Practice Address - Country:US
Practice Address - Phone:217-343-9390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-16
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225C00000X
MO2022045278101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor