MEDICARE: MR. BRADLEY P COSBY

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

General Provider Information

NPI Number	:	1124389408
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRADLEY P COSBY

Provider Business Mailing Address
First Line	:	404 NE 61ST ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73105-1418
Country	:	US
Telephone Number	:	405-633-4433
Fax Number	:

Provider Business Practice Location Address
First Line	:	404 NE 61ST ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73105-1418
Country	:	US
Telephone Number	:	405-633-4433
Fax Number	:

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

Provider Enumeration Date	:	06/04/2012
Last Update Date	:	06/04/2012

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Directions to “ MR. BRADLEY P COSBY ” Practice Location

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