Provider Demographics
NPI:1487907366
Name:BOGDAN, BRADLEY PHILLIP (MSW)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:PHILLIP
Last Name:BOGDAN
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 E 29TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-2623
Mailing Address - Country:US
Mailing Address - Phone:979-436-0483
Mailing Address - Fax:877-601-5854
Practice Address - Street 1:8441 STATE HIGHWAY 47 STE 1400
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77807-3208
Practice Address - Country:US
Practice Address - Phone:979-776-8440
Practice Address - Fax:877-601-5854
Is Sole Proprietor?:No
Enumeration Date:2012-10-17
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX361416602Medicaid