Provider Demographics
NPI:1295351245
Name:FITCH, BRAD
Entity type:Individual
Prefix:
First Name:BRAD
Middle Name:
Last Name:FITCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4405 PADRE BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH PADRE ISLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78597-7324
Mailing Address - Country:US
Mailing Address - Phone:956-299-4712
Mailing Address - Fax:
Practice Address - Street 1:4405 PADRE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH PADRE ISLAND
Practice Address - State:TX
Practice Address - Zip Code:78597-7324
Practice Address - Country:US
Practice Address - Phone:956-299-4712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-24
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX56894Medicaid