MEDICARE: ELYSE WISEMAN BRADFORD BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	6301014952	MI
2	103K00000X	Behavior Analyst	1118442	MI

General Provider Information

NPI Number	:	1093090359
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELYSE WISEMAN BRADFORD BCBA

Provider Business Mailing Address
First Line	:	400 RENAISSANCE CTR
Second Line	:	SUITE 2600
City	:	DETROIT
State	:	MI
Zip	:	48243-1502
Country	:	US
Telephone Number	:	855-832-6727
Fax Number	:	772-675-9100

Provider Business Practice Location Address
First Line	:	400 RENAISSANCE CTR
Second Line	:	SUITE 2600
City	:	DETROIT
State	:	MI
Zip	:	48243-1502
Country	:	US
Telephone Number	:	855-832-6727
Fax Number	:	772-675-9100

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/19/2011
Last Update Date	:	01/07/2016

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