Healthcare Provider Details

I. General information

NPI: 1235611054
Provider Name (Legal Business Name): BRADY TOLLE PCMSW, PLMHP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2018
Last Update Date: 08/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2229 J ST
LINCOLN NE
68510-2933
US

IV. Provider business mailing address

2401 CITY VIEW CT
LINCOLN NE
68521-4154
US

V. Phone/Fax

Practice location:
  • Phone: 402-436-1301
  • Fax:
Mailing address:
  • Phone: 402-641-4338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number7271
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11597
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: