Provider Demographics
NPI:1740605880
Name:FOX, BRADLY
Entity Type:Individual
Prefix:
First Name:BRADLY
Middle Name:
Last Name:FOX
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 1:8623 N WAYNE RD
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-1137
Mailing Address - Country:US
Mailing Address - Phone:313-269-6877
Mailing Address - Fax:
Practice Address - Street 1:8623 N WAYNE RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-1137
Practice Address - Country:US
Practice Address - Phone:313-269-6877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-26
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015311101YM0800X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling