Provider Demographics
NPI:1992439194
Name:LIPP, BRAYDE JAMES (PT, DPT)
Entity type:Individual
Prefix:
First Name:BRAYDE
Middle Name:JAMES
Last Name:LIPP
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 36TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101-1005
Mailing Address - Country:US
Mailing Address - Phone:304-917-3660
Mailing Address - Fax:304-917-3674
Practice Address - Street 1:1521 NORTHWAY DR STE 116
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1274
Practice Address - Country:US
Practice Address - Phone:320-654-9838
Practice Address - Fax:320-654-0981
Is Sole Proprietor?:No
Enumeration Date:2022-07-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1360599225100000X
MN12774225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist