Provider Demographics
NPI:1467112342
Name:CLARK, BRADLEY (MA LPCC LADC)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:MA LPCC LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 974
Mailing Address - Street 2:
Mailing Address - City:LINDSTROM
Mailing Address - State:MN
Mailing Address - Zip Code:55045-0974
Mailing Address - Country:US
Mailing Address - Phone:651-755-4276
Mailing Address - Fax:888-972-5307
Practice Address - Street 1:12814 LAKE BLVD
Practice Address - Street 2:
Practice Address - City:LINDSTROM
Practice Address - State:MN
Practice Address - Zip Code:55045-9345
Practice Address - Country:US
Practice Address - Phone:651-755-4276
Practice Address - Fax:888-972-5307
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-20
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3068101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty