Provider Demographics
NPI:1053911479
Name:BRACKETT, DEMITRIUS (OWNER/DO)
Entity type:Individual
Prefix:
First Name:DEMITRIUS
Middle Name:
Last Name:BRACKETT
Suffix:
Gender:M
Credentials:OWNER/DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 N OTTAWA ST APT 209
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60432-4080
Mailing Address - Country:US
Mailing Address - Phone:815-766-5999
Mailing Address - Fax:
Practice Address - Street 1:311 N OTTAWA ST APT 209
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60432-4080
Practice Address - Country:US
Practice Address - Phone:815-766-5999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-26
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP3300X
IL91079101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain