Provider Demographics
NPI:1427760735
Name:VIVODA, BRADLEY M (CSAC)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:M
Last Name:VIVODA
Suffix:
Gender:M
Credentials:CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 N BALLARD RD
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-8928
Mailing Address - Country:US
Mailing Address - Phone:920-733-4443
Mailing Address - Fax:
Practice Address - Street 1:3301 N BALLARD RD
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-8928
Practice Address - Country:US
Practice Address - Phone:920-733-4443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12488-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)