Provider Demographics
NPI:1154851665
Name:CLARK, BRADY JOSEPH
Entity Type:Individual
Prefix:
First Name:BRADY
Middle Name:JOSEPH
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4055 GARDELLA AVE APT 1413
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89512-1056
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4055 GARDELLA AVE APT 1413
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89512-1056
Practice Address - Country:US
Practice Address - Phone:775-220-9065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-16
Last Update Date:2017-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor