Provider Demographics
NPI:1164250973
Name:HOUSE, BRADLEY WAYNE (MA)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:WAYNE
Last Name:HOUSE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 E KIRK ST
Mailing Address - Street 2:
Mailing Address - City:HUGO
Mailing Address - State:OK
Mailing Address - Zip Code:74743-3607
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1212 E KIRK ST
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:OK
Practice Address - Zip Code:74743-3607
Practice Address - Country:US
Practice Address - Phone:580-326-5279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-23
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health