Provider Demographics
NPI:1437143344
Name:BRAGG, JOHN MARSHALL (LPC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MARSHALL
Last Name:BRAGG
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 SGT ED HOLCOMB BLVD S
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-1990
Mailing Address - Country:US
Mailing Address - Phone:936-521-6300
Mailing Address - Fax:
Practice Address - Street 1:233 SGT ED HOLCOMB BLVD S
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-1990
Practice Address - Country:US
Practice Address - Phone:936-521-6446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15938101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX158253801Medicaid