Provider Demographics
NPI:1710944905
Name:BASE, BRADLEY W (MA)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:W
Last Name:BASE
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 1:322 S LAURA AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67211-1517
Mailing Address - Country:US
Mailing Address - Phone:316-789-4193
Mailing Address - Fax:
Practice Address - Street 1:322 S LAURA AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67211-1517
Practice Address - Country:US
Practice Address - Phone:316-789-4193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1129103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical