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General NPI Number Information
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NPI Number | 1992163638
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Entity Type | Individual
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Provider Name | BRADLEY MARTIN
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Gender | Male
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Dates
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Enumeration Date | 02/09/2016
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Last Update Date | 02/09/2016
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Provider Practice Location Address
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Address Line | 1 VETERANS DR
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City | MINNEAPOLIS
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State | MN
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Zip | 55417-2309
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Country | US
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Telephone | 612-467-2325
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Fax |
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Provider Business Mailing Address
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Address Line | 30435 WALLMARK LAKE DR
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City | CHISAGO CITY
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State | MN
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Zip | 55013-9586
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Country | US
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Telephone | 651-257-3993
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 303536
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 24534
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License Number State | MN
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