Provider Demographics
NPI:1578758819
Name:ROPER, BRADLEY (LCSW)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:ROPER
Suffix:
Gender:M
Credentials:LCSW
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 314
Mailing Address - Street 2:
Mailing Address - City:COWLEY
Mailing Address - State:WY
Mailing Address - Zip Code:82420-0300
Mailing Address - Country:US
Mailing Address - Phone:307-254-5777
Mailing Address - Fax:
Practice Address - Street 1:1201 E 7TH ST
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:WY
Practice Address - Zip Code:82435
Practice Address - Country:US
Practice Address - Phone:307-254-5777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-10
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLCSW-7471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY131120400Medicaid