Provider Demographics
NPI:1124477658
Name:BRUNSON, JOHNATHAN ANTONIO (LCAS-A)
Entity type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:ANTONIO
Last Name:BRUNSON
Suffix:
Gender:M
Credentials:LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 BEECH ST
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27530-2818
Mailing Address - Country:US
Mailing Address - Phone:919-731-2119
Mailing Address - Fax:919-739-4989
Practice Address - Street 1:3011 NC HIGHWAY 42 W
Practice Address - Street 2:SUITE G
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893
Practice Address - Country:US
Practice Address - Phone:252-991-3985
Practice Address - Fax:252-991-3993
Is Sole Proprietor?:No
Enumeration Date:2016-06-06
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
NCLCAS-228861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)