Provider Demographics
NPI:1902822919
Name:NELSON, BRADLEY ROBERT (MALP)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:ROBERT
Last Name:NELSON
Suffix:
Gender:M
Credentials:MALP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 SE 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-3615
Mailing Address - Country:US
Mailing Address - Phone:218-326-1274
Mailing Address - Fax:218-326-9787
Practice Address - Street 1:215 SE 2ND AVE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-3615
Practice Address - Country:US
Practice Address - Phone:218-326-1274
Practice Address - Fax:218-326-9787
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X, 103TC2200X
MNLP0590103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6275968OtherMEDICA
MN160767OtherUCARE
MN3032501OtherPREFERRED ONE
MN97026OtherHEALTH PARTNERS
MN121052100Medicaid
MN4K585NEOtherBCBS