Provider Demographics
NPI:1598355695
Name:HILL, BRADLEY J
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:J
Last Name:HILL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:BRAD
Other - Middle Name:JAMES
Other - Last Name:HILL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:500 MOCKINGBIRD LN
Mailing Address - Street 2:
Mailing Address - City:IDABEL
Mailing Address - State:OK
Mailing Address - Zip Code:74745-3626
Mailing Address - Country:US
Mailing Address - Phone:580-208-0233
Mailing Address - Fax:
Practice Address - Street 1:ADDRESS 1303 SE LYNN LANE
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-3626
Practice Address - Country:US
Practice Address - Phone:580-286-7025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-22
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 175T00000X
OK10484101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No175T00000XOther Service ProvidersPeer Specialist