Healthcare Provider Details

I. General information

NPI: 1205140811
Provider Name (Legal Business Name): MICHAEL W. BRADBURN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2010
Last Update Date: 08/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1819 BAY SCOTT CIR SUITE 109
NAPERVILLE IL
60540-1129
US

IV. Provider business mailing address

1819 BAY SCOTT CIR SUITE 109
NAPERVILLE IL
60540-1129
US

V. Phone/Fax

Practice location:
  • Phone: 630-357-2456
  • Fax: 630-357-2482
Mailing address:
  • Phone: 630-357-2456
  • Fax: 630-357-2482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.008325
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: