=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427087840
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRADLEY JON OOSTINDIE MA, LLP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2006
-----------------------------------------------------
Last Update Date | 06/12/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 S STATE ST STE 13
-----------------------------------------------------
City | ZEELAND
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49464-1678
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-850-0535
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1
-----------------------------------------------------
City | SPRING LAKE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49456-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-850-0535
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 6301009494
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------