=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053772384
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRADY RAY VOIGT LICSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2016
-----------------------------------------------------
Last Update Date | 02/03/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 1ST ST SW
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55905-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-538-9043
-----------------------------------------------------
Fax | 507-538-6622
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 1ST ST SW
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55905-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-538-9043
-----------------------------------------------------
Fax | 507-538-6622
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 22620
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------