Provider Demographics
NPI:1124365234
Name:GOODELL, BRADLEY DENVER JR (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:DENVER
Last Name:GOODELL
Suffix:JR
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 HIGHWAY 96 W
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-1944
Mailing Address - Country:US
Mailing Address - Phone:651-243-1513
Mailing Address - Fax:
Practice Address - Street 1:500 HIGHWAY 96 W
Practice Address - Street 2:SUITE 400
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-1944
Practice Address - Country:US
Practice Address - Phone:651-243-1513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-09
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor