Provider Demographics
NPI:1225715097
Name:GANGNON, BRADLEY A (LADC, ADCR-MN CPRS)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:A
Last Name:GANGNON
Suffix:
Gender:M
Credentials:LADC, ADCR-MN CPRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1516 W LAKE ST # 205
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-2554
Mailing Address - Country:US
Mailing Address - Phone:612-297-1804
Mailing Address - Fax:
Practice Address - Street 1:1516 W LAKE ST # 205
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2554
Practice Address - Country:US
Practice Address - Phone:612-297-1804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-03
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305379101YA0400X
10053940225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner