Provider Demographics
NPI:1861151573
Name:JOHN, BRETTNY
Entity type:Individual
Prefix:
First Name:BRETTNY
Middle Name:
Last Name:JOHN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 WESTOVER DR # 13619
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27330-8941
Mailing Address - Country:US
Mailing Address - Phone:323-205-7088
Mailing Address - Fax:
Practice Address - Street 1:500 WESTOVER DR # 13619
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-8941
Practice Address - Country:US
Practice Address - Phone:323-205-7088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-09
Last Update Date:2025-02-25
Deactivation Date:2024-07-24
Deactivation Code:
Reactivation Date:2025-01-22
Provider Licenses
StateLicense IDTaxonomies
TX78906101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health