Provider Demographics
NPI:1407310113
Name:MITCHELL, BRADLEY J
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:J
Last Name:MITCHELL
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 1:540 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-4913
Mailing Address - Country:US
Mailing Address - Phone:574-300-7068
Mailing Address - Fax:
Practice Address - Street 1:1050 BROADWAY STE 21
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-2173
Practice Address - Country:US
Practice Address - Phone:574-300-7068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-27
Last Update Date:2019-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst