Provider Demographics
NPI:1043517105
Name:FRITTS, BRADI (LCSW)
Entity Type:Individual
Prefix:
First Name:BRADI
Middle Name:
Last Name:FRITTS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 NW 12TH ST
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-5040
Mailing Address - Country:US
Mailing Address - Phone:208-452-6556
Mailing Address - Fax:541-216-6557
Practice Address - Street 1:1100 NW 12TH ST
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-5040
Practice Address - Country:US
Practice Address - Phone:208-739-6248
Practice Address - Fax:541-216-6557
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-24
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-37109104100000X
ORL50681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID804398400Medicaid