Basic Information
| Provider Information | |||||||||
| NPI: | 1992439194 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIPP | ||||||||
| FirstName: | BRAYDE | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 36TH ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | PARKERSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261011005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3049173660 | ||||||||
| FaxNumber: | 3049173674 | ||||||||
| Practice Location | |||||||||
| Address1: | 1521 NORTHWAY DR STE 116 | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563031274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206549838 | ||||||||
| FaxNumber: | 3206540981 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2022 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1360599 | TX | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 12774 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.