Provider Demographics
NPI:1154665214
Name:ROSS, BRADLEY (MS, LPC)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:ROSS
Suffix:
Gender:M
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6317 CENTURY AVE
Mailing Address - Street 2:APT 7
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-2257
Mailing Address - Country:US
Mailing Address - Phone:262-741-3279
Mailing Address - Fax:262-741-3217
Practice Address - Street 1:W4051 COUNTY ROAD NN
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121-4338
Practice Address - Country:US
Practice Address - Phone:262-741-3279
Practice Address - Fax:262-741-3217
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5165-125104100000X
WI542-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1154665214Medicaid