Provider Demographics
NPI:1790941300
Name:RADZOM, BRIAN CHARLES (LCSW)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:CHARLES
Last Name:RADZOM
Suffix:
Gender:M
Credentials:LCSW
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 101
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-0101
Mailing Address - Country:US
Mailing Address - Phone:618-248-2040
Mailing Address - Fax:618-248-2040
Practice Address - Street 1:205 S MAIN ST
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-1921
Practice Address - Country:US
Practice Address - Phone:618-248-2040
Practice Address - Fax:618-248-2040
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-03
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490127061041C0700X
MO20070336481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical