Healthcare Provider Details

I. General information

NPI: 1699124115
Provider Name (Legal Business Name): BRADFORD WYE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2016
Last Update Date: 06/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 E PATRICK ST
FREDERICK MD
21701-5614
US

IV. Provider business mailing address

309 E PATRICK ST
FREDERICK MD
21701-5614
US

V. Phone/Fax

Practice location:
  • Phone: 240-357-5453
  • Fax:
Mailing address:
  • Phone: 240-357-5453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number16482
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: