Provider Demographics
NPI:1437224854
Name:VANGORKOM, BRADLEY JAY (MSW LISW)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:JAY
Last Name:VANGORKOM
Suffix:
Gender:M
Credentials:MSW LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1935 1ST AVE SE
Mailing Address - Street 2:SUITE D
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-5325
Mailing Address - Country:US
Mailing Address - Phone:319-531-1158
Mailing Address - Fax:319-538-0461
Practice Address - Street 1:1935 1ST AVE SE
Practice Address - Street 2:SUITE D
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-5325
Practice Address - Country:US
Practice Address - Phone:319-531-1158
Practice Address - Fax:319-538-0461
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06248104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1707310Medicaid
IA0707310Medicaid
IA2707310Medicaid