Provider Demographics
NPI:1013794585
Name:BRADLEY, MATTHEW D (LLMSW)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:D
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:BIG RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49307-1446
Mailing Address - Country:US
Mailing Address - Phone:231-527-5415
Mailing Address - Fax:
Practice Address - Street 1:110 SANBORN AVE STE B
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-1769
Practice Address - Country:US
Practice Address - Phone:231-527-5415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511173391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical