Provider Demographics
NPI:1891027819
Name:BRUNELLE, JOHN PAUL (PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PAUL
Last Name:BRUNELLE
Suffix:
Gender:M
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-365-6730
Mailing Address - Fax:704-365-6731
Practice Address - Street 1:4741 RANDOLPH RD STE 100
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-2919
Practice Address - Country:US
Practice Address - Phone:704-365-6730
Practice Address - Fax:704-365-6731
Is Sole Proprietor?:No
Enumeration Date:2010-02-01
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEB1-0000738103T00000X
NC4190103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist