MEDICARE: BRADLEY PHILLIP BOGDAN MSW

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	104100000X	Social Worker
2	1041C0700X	Clinical Social Worker

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487907366
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRADLEY PHILLIP BOGDAN MSW

Provider Business Mailing Address
First Line	:	2900 E 29TH ST STE 100
Second Line	:
City	:	BRYAN
State	:	TX
Zip	:	77802-2623
Country	:	US
Telephone Number	:	979-436-0483
Fax Number	:	877-601-5854

Provider Business Practice Location Address
First Line	:	8441 STATE HIGHWAY 47 STE 1400
Second Line	:
City	:	BRYAN
State	:	TX
Zip	:	77807-3208
Country	:	US
Telephone Number	:	979-776-8440
Fax Number	:	877-601-5854

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

Provider Enumeration Date	:	10/17/2012
Last Update Date	:	07/15/2020

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Directions to “ BRADLEY PHILLIP BOGDAN MSW” Practice Location

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