Basic Information
| Provider Information | |||||||||
| NPI: | 1134107824 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRAMBLETT | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | PAUL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 696 | ||||||||
| Address2: | |||||||||
| City: | HAMPSTEAD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107916767 | ||||||||
| FaxNumber: | 9107916890 | ||||||||
| Practice Location | |||||||||
| Address1: | 311 4E JUDGES ROAD | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107916767 | ||||||||
| FaxNumber: | 9107916890 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 2291 | NC | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 045MA | 01 | NC | BCBS | OTHER | 6000191 | 05 | NC | MEDICAID |