Healthcare Provider Details

I. General information

NPI: 1215002522
Provider Name (Legal Business Name): BRAD M SEWALL MS LCMHC RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 11/21/2022
Certification Date: 11/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 SCHOOL STREET
HARTFORD VT
05047
US

IV. Provider business mailing address

P.O. BOX 709
HARTFORD VT
05047-0709
US

V. Phone/Fax

Practice location:
  • Phone: 802-295-3031
  • Fax: 802-295-0820
Mailing address:
  • Phone: 802-295-3031
  • Fax: 802-295-0820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number026.0067516
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number064206-21
License Number StateNH
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number068.0000560
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: