Provider Demographics
NPI:1700937034
Name:BRACCIO, JOHN H (PHD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:H
Last Name:BRACCIO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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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:517-332-2960
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:517-332-2960
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI#6301001831103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI620C3-4546OtherBCBS
MI005-38247204200OtherCIGNA
MI620C3-4546OtherBCBS