=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215373428
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRAD HERMAN LADC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2013
-----------------------------------------------------
Last Update Date | 05/16/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7400 EDINBOROUGH WAY #5312
-----------------------------------------------------
City | EDINA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55435-5615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-233-0797
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7400 EDINBOROUGH WAY #5312
-----------------------------------------------------
City | EDINA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55435-5615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-233-0797
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 302934
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------