Basic Information
| Provider Information | |||||||||
| NPI: | 1952558934 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADDOCK | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | CHRISTOPHER | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9054 | ||||||||
| Address2: | |||||||||
| City: | GRAY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376159054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234673600 | ||||||||
| FaxNumber: | 4234673644 | ||||||||
| Practice Location | |||||||||
| Address1: | 26 MIDWAY ST | ||||||||
| Address2: | |||||||||
| City: | BRISTOL | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376201706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239894500 | ||||||||
| FaxNumber: | 4234673644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2008 | ||||||||
| LastUpdateDate: | 10/04/2018 | ||||||||
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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 | 4388 | TN | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.