Provider Demographics
NPI:1285852533
Name:CORREGAN, BRUCE HUNTER (MA)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:HUNTER
Last Name:CORREGAN
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 N SUMMIT DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-8991
Mailing Address - Country:US
Mailing Address - Phone:336-755-8221
Mailing Address - Fax:
Practice Address - Street 1:847 W LAKE DR
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-2157
Practice Address - Country:US
Practice Address - Phone:336-783-6919
Practice Address - Fax:336-786-6312
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCS2918101YP2500X
NC472101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102323Medicaid