Basic Information
| Provider Information | |||||||||
| NPI: | 1356344469 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEEBE | ||||||||
| FirstName: | BRADFORD | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | PHD, HSPP, BCBA-D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3500 DEPAUW BLVD STE 3070 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462686135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8553240885 | ||||||||
| FaxNumber: | 7654549759 | ||||||||
| Practice Location | |||||||||
| Address1: | 355 QUARTERMASTER CT | ||||||||
| Address2: | |||||||||
| City: | JEFFERSONVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471303670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122589802 | ||||||||
| FaxNumber: | 7654549759 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2005 | ||||||||
| LastUpdateDate: | 11/22/2017 | ||||||||
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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 | 103K00000X | 101602 | KY | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 103K00000X | COBA.122 | OH | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 103T00000X | 128036 | KY | N | Behavioral Health & Social Service Providers | Psychologist | 103T00000X | 0834 | KY | N | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | 20040970A | IN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 128036 | KY | N | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 200185410A | 05 | IN | MEDICAID | 1-04-2089 | 01 | BCBA-D CERTIFICATE | OTHER |