MEDICARE: BRAD ILLIAN MA, MLADC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1619691235
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRAD ILLIAN MA, MLADC

Provider Business Mailing Address
First Line	:	112 S STATE ST
Second Line	:
City	:	CONCORD
State	:	NH
Zip	:	03301-3528
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	112 S STATE ST
Second Line	:
City	:	CONCORD
State	:	NH
Zip	:	03301-3528
Country	:	US
Telephone Number	:	603-998-4210
Fax Number	:

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

Provider Enumeration Date	:	09/27/2022
Last Update Date	:	06/28/2024

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