Healthcare Provider Details

I. General information

NPI: 1487134797
Provider Name (Legal Business Name): BRADLEY WALLACE SHEPPARD BSW LLBSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2018
Last Update Date: 08/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 S M 30
WEST BRANCH MI
48661-8711
US

IV. Provider business mailing address

PO BOX 310
TAWAS CITY MI
48764-0310
US

V. Phone/Fax

Practice location:
  • Phone: 989-345-5571
  • Fax: 989-345-4111
Mailing address:
  • Phone: 989-362-8636
  • Fax: 989-345-4111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6802088639
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: