Basic Information
| Provider Information | |||||||||
| NPI: | 1336248137 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NEVINS | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 204 S ADAMS ST | ||||||||
| Address2: | |||||||||
| City: | SAINT CROIX FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540249449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154833221 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 204 S ADAMS ST | ||||||||
| Address2: | |||||||||
| City: | SAINT CROIX FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540249449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154833221 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 1436-057 | WI | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 31G80NE | 01 | MN | BLUE CROSS FACILITY | OTHER | 165875100 | 05 | MN | MEDICAID | NA9031023578 | 01 | PREFERREDONE | OTHER | 39087700 | 05 | WI | MEDICAID | 86D52NE | 01 | MN | BLUE CROSS PRO FEE | OTHER | HP30609 | 01 | HEALTHPARTNERS | OTHER | 620006571 | 01 | RAILROAD MEDICARE | OTHER |