Provider Demographics
NPI:1639530777
Name:BRAZELTON, MICHAEL JAY (IADC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAY
Last Name:BRAZELTON
Suffix:
Gender:M
Credentials:IADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 5TH AVENUE
Mailing Address - Street 2:SUITE 600
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50309
Mailing Address - Country:US
Mailing Address - Phone:515-243-4200
Mailing Address - Fax:515-284-5201
Practice Address - Street 1:505 5TH AVENUE
Practice Address - Street 2:SUITE 600
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309
Practice Address - Country:US
Practice Address - Phone:515-243-4200
Practice Address - Fax:515-284-5201
Is Sole Proprietor?:No
Enumeration Date:2016-03-17
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAIADC-06114101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor