Provider Demographics
NPI:1255944252
Name:BRANCH, LAKEITHA TRADELL (LAC)
Entity type:Individual
Prefix:
First Name:LAKEITHA
Middle Name:TRADELL
Last Name:BRANCH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:732 AVENUE E APT 411
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-4392
Mailing Address - Country:US
Mailing Address - Phone:347-351-8441
Mailing Address - Fax:
Practice Address - Street 1:275 BLOOMFIELD AVE STE 4
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:NJ
Practice Address - Zip Code:07006-5100
Practice Address - Country:US
Practice Address - Phone:862-206-7232
Practice Address - Fax:973-860-0717
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00283900101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health