MEDICARE: BRADLEY MARVIN HEAD LPC

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	101YP2500X	Professional Counselor	LPC0637	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	742488	OTHER	AZ	AHCCCS

General Provider Information

NPI Number	:	1417912304
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRADLEY MARVIN HEAD LPC

Provider Business Mailing Address
First Line	:	2550 SHOW LOW LAKE ROAD
Second Line	:
City	:	SHOW LOW
State	:	AZ
Zip	:	85901-7929
Country	:	US
Telephone Number	:	928-537-1029
Fax Number	:	928-537-9049

Provider Business Practice Location Address
First Line	:	2550 SHOW LOW LAKE ROAD
Second Line	:
City	:	SHOW LOW
State	:	AZ
Zip	:	85901-7929
Country	:	US
Telephone Number	:	928-537-1029
Fax Number	:	928-537-9049

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

Provider Enumeration Date	:	04/20/2006
Last Update Date	:	07/08/2007

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