Healthcare Provider Details

I. General information

NPI: 1447865563
Provider Name (Legal Business Name): BRADLEY RAY MAXWELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2020
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 E JEFFERSON ST
HUGO OK
74743-5217
US

IV. Provider business mailing address

1301 E JEFFERSON ST
HUGO OK
74743-5217
US

V. Phone/Fax

Practice location:
  • Phone: 580-372-1058
  • Fax:
Mailing address:
  • Phone: 580-372-1058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number11545
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: