MEDICARE: BRADLEY PATITZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1275049991
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRADLEY PATITZ

Provider Business Mailing Address
First Line	:	5556 N MERIDIAN ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46208-2658
Country	:	US
Telephone Number	:	317-334-7331
Fax Number	:

Provider Business Practice Location Address
First Line	:	451 S PARK RIDGE RD STE 102
Second Line	:
City	:	BLOOMINGTON
State	:	IN
Zip	:	47401-8589
Country	:	US
Telephone Number	:	812-822-0189
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/18/2017
Last Update Date	:	12/18/2017

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Directions to “ BRADLEY PATITZ ” Practice Location

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