Provider Demographics
NPI:1639993413
Name:HARALSON, BRAXTON TRENT
Entity type:Individual
Prefix:
First Name:BRAXTON
Middle Name:TRENT
Last Name:HARALSON
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 1:7 DUNLAP ST
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-0745
Mailing Address - Country:US
Mailing Address - Phone:706-818-3185
Mailing Address - Fax:
Practice Address - Street 1:2476 US HIGHWAY 280
Practice Address - Street 2:
Practice Address - City:AILEY
Practice Address - State:GA
Practice Address - Zip Code:30410-3538
Practice Address - Country:US
Practice Address - Phone:404-924-6220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-08
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician