MEDICARE: MR. BRADFORD RANDALL BROWN ALC, MDIV

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	04483	AL

General Provider Information

NPI Number	:	1679346324
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRADFORD RANDALL BROWN ALC, MDIV

Provider Business Mailing Address
First Line	:	402 OFFICE PARK DR STE 290
Second Line	:
City	:	MOUNTAIN BRK
State	:	AL
Zip	:	35223-3100
Country	:	US
Telephone Number	:	205-918-6161
Fax Number	:

Provider Business Practice Location Address
First Line	:	402 OFFICE PARK DR STE 290
Second Line	:
City	:	MOUNTAIN BRK
State	:	AL
Zip	:	35223-3100
Country	:	US
Telephone Number	:	205-918-6161
Fax Number	:

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

Provider Enumeration Date	:	11/03/2023
Last Update Date	:	11/03/2023

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