Healthcare Provider Details

I. General information

NPI: 1588176606
Provider Name (Legal Business Name): BRADLEY KEEP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2017
Last Update Date: 10/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4610 W 9980 N
CEDAR HILLS UT
84062-8728
US

IV. Provider business mailing address

4610 W 9980 N
CEDAR HILLS UT
84062-8728
US

V. Phone/Fax

Practice location:
  • Phone: 801-636-0674
  • Fax: 801-636-0674
Mailing address:
  • Phone: 801-636-0674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number7667842-4405
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: