MEDICARE: BRADLEY CLARK MA LPCC LADC

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	101YM0800X	Mental Health Counselor	3068	MN

General Provider Information

NPI Number	:	1467112342
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRADLEY CLARK MA LPCC LADC

Provider Business Mailing Address
First Line	:	PO BOX 974
Second Line	:
City	:	LINDSTROM
State	:	MN
Zip	:	55045-0974
Country	:	US
Telephone Number	:	651-755-4276
Fax Number	:	888-972-5307

Provider Business Practice Location Address
First Line	:	12814 LAKE BLVD
Second Line	:
City	:	LINDSTROM
State	:	MN
Zip	:	55045-9345
Country	:	US
Telephone Number	:	651-755-4276
Fax Number	:	888-972-5307

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

Provider Enumeration Date	:	12/20/2021
Last Update Date	:	12/20/2021

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