Provider Demographics
NPI:1154303840
Name:BRAZELTON, JOAN (MSW)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:BRAZELTON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 S DORT HWY
Mailing Address - Street 2:SUITE 44
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-2093
Mailing Address - Country:US
Mailing Address - Phone:810-744-3300
Mailing Address - Fax:810-744-1090
Practice Address - Street 1:3600 S DORT HWY
Practice Address - Street 2:SUITE 44
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-2093
Practice Address - Country:US
Practice Address - Phone:810-744-3300
Practice Address - Fax:810-744-1090
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010341271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801034127OtherLMSW
OB56322001Medicare ID - Type Unspecified