Healthcare Provider Details

I. General information

NPI: 1902822919
Provider Name (Legal Business Name): BRADLEY ROBERT NELSON MALP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 01/31/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 SE 2ND AVE
GRAND RAPIDS MN
55744-3615
US

IV. Provider business mailing address

215 SE 2ND AVE
GRAND RAPIDS MN
55744-3615
US

V. Phone/Fax

Practice location:
  • Phone: 218-326-1274
  • Fax: 218-326-9787
Mailing address:
  • Phone: 218-326-1274
  • Fax: 218-326-9787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberLP0590
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: