Provider Demographics
NPI:1801006259
Name:BRAZELTON, MARY JO (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:JO
Last Name:BRAZELTON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7771 WILDCREEK TRL SE
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35802-3926
Mailing Address - Country:US
Mailing Address - Phone:256-270-4800
Mailing Address - Fax:256-428-8059
Practice Address - Street 1:7771 WILDCREEK TRL SE
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35802-3926
Practice Address - Country:US
Practice Address - Phone:256-270-4800
Practice Address - Fax:256-428-8059
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 002725103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist