Provider Demographics
NPI:1053778589
Name:BRACCIO, JOHN ANTHONY (PHD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ANTHONY
Last Name:BRACCIO
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 1:1401 E LANSING DR STE 111
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-2992
Mailing Address - Country:US
Mailing Address - Phone:517-332-0153
Mailing Address - Fax:
Practice Address - Street 1:1401 E LANSING DR STE 111
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-2992
Practice Address - Country:US
Practice Address - Phone:517-332-0153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-28
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016571103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist