Provider Demographics
NPI:1336133651
Name:GARSON, BRADLEY C (MSSW LCSW)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:C
Last Name:GARSON
Suffix:
Gender:M
Credentials:MSSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 N 1ST ST
Mailing Address - Street 2:PO BOX 387
Mailing Address - City:BLACK RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54615-1311
Mailing Address - Country:US
Mailing Address - Phone:715-284-0361
Mailing Address - Fax:715-333-5007
Practice Address - Street 1:54 N 1ST ST
Practice Address - Street 2:
Practice Address - City:BLACK RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54615-1311
Practice Address - Country:US
Practice Address - Phone:715-797-5007
Practice Address - Fax:715-333-5007
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-01
Last Update Date:2007-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2907-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39655500Medicaid