Basic Information
| Provider Information | |||||||||
| NPI: | 1285852533 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CORREGAN | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | HUNTER | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 137 N SUMMIT DR | ||||||||
| Address2: | |||||||||
| City: | MOUNT AIRY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270308991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367558221 | ||||||||
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| Practice Location | |||||||||
| Address1: | 847 W LAKE DR | ||||||||
| Address2: | |||||||||
| City: | MOUNT AIRY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270302157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367836919 | ||||||||
| FaxNumber: | 3367866312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2007 | ||||||||
| LastUpdateDate: | 07/31/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | S2918 | NC | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YA0400X | 472 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 6102323 | 05 | NC | MEDICAID |