Healthcare Provider Details

I. General information

NPI: 1407242837
Provider Name (Legal Business Name): JOEL BRADLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2015
Last Update Date: 04/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7086 8TH AVE
JENISON MI
49428-9352
US

IV. Provider business mailing address

214 SUMMIT ST
SPRING LAKE MI
49456-2057
US

V. Phone/Fax

Practice location:
  • Phone: 616-667-9551
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801094199
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: