Provider Demographics
NPI:1811702848
Name:MACOUBRIE, BRADLY GRANT (RN)
Entity type:Individual
Prefix:
First Name:BRADLY
Middle Name:GRANT
Last Name:MACOUBRIE
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3308 S COCHISE AVE
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64057-1856
Mailing Address - Country:US
Mailing Address - Phone:816-786-5057
Mailing Address - Fax:
Practice Address - Street 1:4801 E LINWOOD BLVD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64128-2226
Practice Address - Country:US
Practice Address - Phone:816-861-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-07
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010021448163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)