Provider Demographics
NPI:1962024786
Name:MIRBON, BRADLEY
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:MIRBON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3829 HOLLYWOOD BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-6790
Mailing Address - Country:US
Mailing Address - Phone:954-367-3600
Mailing Address - Fax:
Practice Address - Street 1:3829 HOLLYWOOD BLVD STE D
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-6790
Practice Address - Country:US
Practice Address - Phone:954-367-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-14
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104994800Medicaid