Provider Demographics
NPI:1235316381
Name:HAWBECKER, BRADLEY RAY (SAC 15654-131)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:RAY
Last Name:HAWBECKER
Suffix:
Gender:M
Credentials:SAC 15654-131
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2422 N GRANDVIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-6105
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2240 PRAIRE AVE
Practice Address - Street 2:10
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-2940
Practice Address - Country:US
Practice Address - Phone:608-361-7200
Practice Address - Fax:608-361-7201
Is Sole Proprietor?:No
Enumeration Date:2008-01-30
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15654-131101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42247900Medicaid