Healthcare Provider Details

I. General information

NPI: 1083186712
Provider Name (Legal Business Name): BRADLEY MALLINGER MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2018
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20370 POE SHOLES DR
BEND OR
97703-7938
US

IV. Provider business mailing address

20370 POE SHOLES DR
BEND OR
97703-7938
US

V. Phone/Fax

Practice location:
  • Phone: 541-318-1377
  • Fax:
Mailing address:
  • Phone: 541-318-1377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: