Healthcare Provider Details

I. General information

NPI: 1811702848
Provider Name (Legal Business Name): BRADLY GRANT MACOUBRIE RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2025
Last Update Date: 02/07/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 E LINWOOD BLVD
KANSAS CITY MO
64128-2226
US

IV. Provider business mailing address

3308 S COCHISE AVE
INDEPENDENCE MO
64057-1856
US

V. Phone/Fax

Practice location:
  • Phone: 816-861-4700
  • Fax:
Mailing address:
  • Phone: 816-786-5057
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number2010021448
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: