Healthcare Provider Details

I. General information

NPI: 1801429378
Provider Name (Legal Business Name): BRADLEY J REDEKER, LMSW, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2020
Last Update Date: 02/22/2020
Certification Date: 02/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3280 E BELTLINE CT NE STE 100
GRAND RAPIDS MI
49525-9494
US

IV. Provider business mailing address

5510 LILLY CT SW
WYOMING MI
49509-9204
US

V. Phone/Fax

Practice location:
  • Phone: 616-610-9994
  • Fax:
Mailing address:
  • Phone: 616-258-0687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MR. BRADLEY REDEKER
Title or Position: CLINICAL SOCIAL WORKER
Credential: LMSW, APBCC, CCTP
Phone: 616-258-0687