=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366844300
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTOPHER L BRADY LMSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2014
-----------------------------------------------------
Last Update Date | 06/06/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 725 S ADAMS RD STE L-167
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48009-6987
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-231-3620
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2904 GRAYSON ST APT A
-----------------------------------------------------
City | FERNDALE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48220-1097
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-231-3620
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 6801096831
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------