Provider Demographics
NPI:1356344469
Name:BEEBE, BRADFORD MICHAEL (PHD, HSPP, BCBA-D)
Entity type:Individual
Prefix:
First Name:BRADFORD
Middle Name:MICHAEL
Last Name:BEEBE
Suffix:
Gender:M
Credentials:PHD, HSPP, BCBA-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:765-454-9759
Practice Address - Street 1:355 QUARTERMASTER CT
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3670
Practice Address - Country:US
Practice Address - Phone:812-258-9802
Practice Address - Fax:765-454-9759
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2017-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY101602103K00000X
OHCOBA.122103K00000X
KY128036103T00000X, 103TC0700X
KY0834103T00000X
IN20040970A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200185410AMedicaid
1-04-2089OtherBCBA-D CERTIFICATE
IN200185410AMedicaid
KY0676414Medicare ID - Type Unspecified