Provider Demographics
NPI:1598148496
Name:BRACCO, PHILLIP
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:BRACCO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 ISLAND RD
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:RAMSEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07446-2813
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:545 ISLAND RD
Practice Address - Street 2:SUITE 2B
Practice Address - City:RAMSEY
Practice Address - State:NJ
Practice Address - Zip Code:07446-2813
Practice Address - Country:US
Practice Address - Phone:201-995-1004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-09
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37FI00178400106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist