Provider Demographics
NPI:1558632083
Name:BRANHAM, BRADLEY R (MA, LMFT)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:R
Last Name:BRANHAM
Suffix:
Gender:M
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1875 STATION PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-3319
Mailing Address - Country:US
Mailing Address - Phone:763-482-9598
Mailing Address - Fax:
Practice Address - Street 1:1875 STATION PKWY NW
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-3319
Practice Address - Country:US
Practice Address - Phone:763-482-9598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-13
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2001106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist