Basic Information
| Provider Information | |||||||||
| NPI: | 1821159831 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRAUDY | ||||||||
| FirstName: | RENATA | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BEAMAN | ||||||||
| OtherFirstName: | RENATA | ||||||||
| OtherMiddleName: | BRAUDY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7581 9TH ST N STE 100 | ||||||||
| Address2: | |||||||||
| City: | OAKDALE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551286635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6517484338 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5959 BAKER RD STE 340 | ||||||||
| Address2: | |||||||||
| City: | MINNETONKA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553455984 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513487428 | ||||||||
| FaxNumber: | 6513487432 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 07/08/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5989 | AZ | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 9160 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 756140 | 05 | AZ | MEDICAID |