Provider Demographics
NPI:1629244033
Name:BANDEMER, BRADFORD J
Entity Type:Individual
Prefix:
First Name:BRADFORD
Middle Name:J
Last Name:BANDEMER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 E WASHINGTON AVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2393
Mailing Address - Country:US
Mailing Address - Phone:517-782-0100
Mailing Address - Fax:517-782-1195
Practice Address - Street 1:209 E WASHINGTON AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-2393
Practice Address - Country:US
Practice Address - Phone:517-782-0100
Practice Address - Fax:517-782-1195
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401002118101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional