Healthcare Provider Details

I. General information

NPI: 1235330846
Provider Name (Legal Business Name): MR. BRAD R BULDAK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 E WASHINGTON ST
CHAMPAIGN IL
61820-3652
US

IV. Provider business mailing address

1401 WINDING LN
CHAMPAIGN IL
61820-2631
US

V. Phone/Fax

Practice location:
  • Phone: 217-398-7785
  • Fax: 217-398-7787
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: