Provider Demographics
NPI:1154665214
Name:ROSS, BRADLEY (MS, LPC)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:ROSS
Suffix:
Gender:
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N28W6284 ALYCE ST APT 233
Mailing Address - Street 2:
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012-2741
Mailing Address - Country:US
Mailing Address - Phone:414-937-1073
Mailing Address - Fax:
Practice Address - Street 1:5650 N GREEN BAY AVE STE 205
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53209-4446
Practice Address - Country:US
Practice Address - Phone:262-678-9119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5165-125101YP2500X
WI542-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1154665214Medicaid