Healthcare Provider Details

I. General information

NPI: 1124477658
Provider Name (Legal Business Name): JOHNATHAN ANTONIO BRUNSON LCAS-A
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2016
Last Update Date: 08/04/2020
Certification Date: 08/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3011 NC HIGHWAY 42 W SUITE G
WILSON NC
27893
US

IV. Provider business mailing address

307 BEECH ST
GOLDSBORO NC
27530-2818
US

V. Phone/Fax

Practice location:
  • Phone: 252-991-3985
  • Fax: 252-991-3993
Mailing address:
  • Phone: 919-731-2119
  • Fax: 919-739-4989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: