Provider Demographics
NPI:1609231638
Name:RICHARDS-BRADT, MICHAEL JAMES (MA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:RICHARDS-BRADT
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1233 SHELBURNE RD STE 360
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-7752
Mailing Address - Country:US
Mailing Address - Phone:802-497-1920
Mailing Address - Fax:
Practice Address - Street 1:1233 SHELBURNE RD STE 360
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-7752
Practice Address - Country:US
Practice Address - Phone:802-383-8543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-17
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT047.0098988103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1026473Medicaid