Healthcare Provider Details

I. General information

NPI: 1487138061
Provider Name (Legal Business Name): BRAD JOSEPH NELSON MSW, LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2018
Last Update Date: 04/05/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 WASHIGTON ST STE 2
MONTPELIER ID
83254-1600
US

IV. Provider business mailing address

455 WASHINGTON ST STE 2
MONTPELIER ID
83254-1600
US

V. Phone/Fax

Practice location:
  • Phone: 208-847-4464
  • Fax: 208-847-3093
Mailing address:
  • Phone: 208-847-4464
  • Fax: 208-847-3093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-38058
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: