Provider Demographics
NPI:1053571646
Name:WILLBORN, BRADLEY R (BS, MSE)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:R
Last Name:WILLBORN
Suffix:
Gender:M
Credentials:BS, MSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:627 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DARLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53530-1395
Mailing Address - Country:US
Mailing Address - Phone:608-776-4800
Mailing Address - Fax:608-776-4914
Practice Address - Street 1:627 MAIN ST
Practice Address - Street 2:
Practice Address - City:DARLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53530-1395
Practice Address - Country:US
Practice Address - Phone:608-776-4800
Practice Address - Fax:608-776-4914
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical