Provider Demographics
NPI:1356739106
Name:BRAXTON, LATOYA RENEE' (MED, EDS,IMF,PCCI)
Entity type:Individual
Prefix:MISS
First Name:LATOYA
Middle Name:RENEE'
Last Name:BRAXTON
Suffix:
Gender:F
Credentials:MED, EDS,IMF,PCCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3478 BUSKIRK AVE STE 260
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523-4358
Mailing Address - Country:US
Mailing Address - Phone:925-360-3994
Mailing Address - Fax:
Practice Address - Street 1:3478 BUSKIRK AVE
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523-4344
Practice Address - Country:US
Practice Address - Phone:925-360-3994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-02
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPCCI2772101YM0800X
CAIMF83180106H00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist