Provider Demographics
NPI:1477524940
Name:WEISCHEDEL, BRADLEY DEAN (LCSW)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:DEAN
Last Name:WEISCHEDEL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:BRADLEY
Other - Middle Name:
Other - Last Name:WEISCHEDEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:87 W 300 N
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84103-1959
Mailing Address - Country:US
Mailing Address - Phone:801-949-8911
Mailing Address - Fax:
Practice Address - Street 1:4460 HIGHLAND DR
Practice Address - Street 2:SUITE 100
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-3543
Practice Address - Country:US
Practice Address - Phone:801-273-4094
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT29547635011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP92704Medicare UPIN