Provider Demographics
NPI:1336248137
Name:NEVINS, BRADLEY G (PHD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:G
Last Name:NEVINS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 S ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CROIX FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54024-9449
Mailing Address - Country:US
Mailing Address - Phone:715-483-3221
Mailing Address - Fax:
Practice Address - Street 1:204 S ADAMS ST
Practice Address - Street 2:
Practice Address - City:SAINT CROIX FALLS
Practice Address - State:WI
Practice Address - Zip Code:54024-9449
Practice Address - Country:US
Practice Address - Phone:715-483-3221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1436-057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN31G80NEOtherBLUE CROSS FACILITY
MN165875100Medicaid
NA9031023578OtherPREFERREDONE
WI39087700Medicaid
MN86D52NEOtherBLUE CROSS PRO FEE
HP30609OtherHEALTHPARTNERS
620006571OtherRAILROAD MEDICARE
HP30609OtherHEALTHPARTNERS
MN165875100Medicaid