Provider Demographics
NPI:1487892428
Name:CONN, BRAD ELLIS (MA)
Entity type:Individual
Prefix:
First Name:BRAD
Middle Name:ELLIS
Last Name:CONN
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:BRADFIELD
Other - Middle Name:ELLIS
Other - Last Name:CONN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:10421 S FIGUEROA ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90003-4423
Mailing Address - Country:US
Mailing Address - Phone:310-738-4620
Mailing Address - Fax:
Practice Address - Street 1:10421 S FIGUEROA ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90003-4423
Practice Address - Country:US
Practice Address - Phone:310-738-4620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-29
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health