MEDICARE: BRADLEY BONNETT

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	106H00000X	Marriage & Family Therapist	1984	MN

General Provider Information

NPI Number	:	1629362124
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRADLEY BONNETT

Provider Business Mailing Address
First Line	:	1317 4TH AVE
Second Line	:
City	:	WORTHINGTON
State	:	MN
Zip	:	56187-2446
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	401 WEST ST STE 115
Second Line	:
City	:	JACKSON
State	:	MN
Zip	:	56143-1219
Country	:	US
Telephone Number	:	507-847-2423
Fax Number	:

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

Provider Enumeration Date	:	06/02/2011
Last Update Date	:	10/15/2018

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Directions to “ BRADLEY BONNETT ” Practice Location

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