Provider Demographics
NPI:1982796074
Name:BROWN, BRADLEY THOMAS (LAC)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:THOMAS
Last Name:BROWN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1612 1ST ST E
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-4271
Mailing Address - Country:US
Mailing Address - Phone:701-793-2736
Mailing Address - Fax:
Practice Address - Street 1:2624 9TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-2350
Practice Address - Country:US
Practice Address - Phone:701-298-4500
Practice Address - Fax:701-298-4400
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1332101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND21466OtherBCBS
412781020163OtherPREFERRED ONE