Provider Demographics
NPI:1134107824
Name:BRAMBLETT, JOHN PAUL JR (PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PAUL
Last Name:BRAMBLETT
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 696
Mailing Address - Street 2:
Mailing Address - City:HAMPSTEAD
Mailing Address - State:NC
Mailing Address - Zip Code:28443
Mailing Address - Country:US
Mailing Address - Phone:910-791-6767
Mailing Address - Fax:910-791-6890
Practice Address - Street 1:311 4E JUDGES ROAD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28405
Practice Address - Country:US
Practice Address - Phone:910-791-6767
Practice Address - Fax:910-791-6890
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2291103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC045MAOtherBCBS
NC6000191Medicaid
NC6000191Medicaid