Provider Demographics
NPI:1447865563
Name:MAXWELL, BRADLEY RAY
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:RAY
Last Name:MAXWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 E JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:HUGO
Mailing Address - State:OK
Mailing Address - Zip Code:74743-5217
Mailing Address - Country:US
Mailing Address - Phone:580-372-1058
Mailing Address - Fax:
Practice Address - Street 1:1301 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:OK
Practice Address - Zip Code:74743-5217
Practice Address - Country:US
Practice Address - Phone:580-372-1058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator