Provider Demographics
NPI:1760870661
Name:DICKEY, BRAD (BCBA)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:
Last Name:DICKEY
Suffix:
Gender:M
Credentials:BCBA
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 11231
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002
Mailing Address - Country:US
Mailing Address - Phone:715-829-5195
Mailing Address - Fax:
Practice Address - Street 1:536 E KELLY AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8546
Practice Address - Country:US
Practice Address - Phone:715-829-5195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-30
Last Update Date:2017-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1-12-11844103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst