Provider Demographics
NPI:1801935549
Name:SEWICK, BRADLEY GEORGE (PHD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:GEORGE
Last Name:SEWICK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26555 EVERGREEN ROAD
Mailing Address - Street 2:SUITE #830
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-4239
Mailing Address - Country:US
Mailing Address - Phone:248-350-3650
Mailing Address - Fax:248-350-1216
Practice Address - Street 1:26555 EVERGREEN ROAD
Practice Address - Street 2:SUITE #830
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-4239
Practice Address - Country:US
Practice Address - Phone:248-350-3650
Practice Address - Fax:248-350-1216
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005256103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1193960001Medicaid
OF34776Medicare UPIN
MIOF34776Medicare ID - Type Unspecified