NPIMap

Individual provider Active NPI

Larry Miles Bradley, LCSW

  • Clinical Social Worker
  • Saint Anthony, ID
National Provider Identifier
1891139432
Registry record updated Jun 3, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical Social WorkerTaxonomy code 1041C0700X
License
LCSW 30350 Issued in ID
Practice address
335 E Main St Ste 1
Saint Anthony, ID 83445-1546
Phone
(208) 356-4900
Fax
(208) 624-4030
NPI assigned
Apr 25, 2013
Last updated
Jun 3, 2024By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jun 3, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical Social Worker 1041C0700X LCSW 30350 ID Primary

Addresses

Primary practice location

335 E Main St Ste 1
Saint Anthony, ID 83445-1546

Mailing address

PO Box 18
Saint Anthony, ID 83445-0018
Phone (208) 356-4900

Other practice location 1

72 S 1st E Ste 101
Rexburg, ID 83440-1965
Phone (208) 356-4900

Other practice location 2

3729 Woodking Dr Ste 1
Idaho Falls, ID 83404-4720
Phone (208) 356-4900

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ID
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20180521002199 ID Practitioner - Clinical Social Worker 1153686209 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Clinical Social Worker
Education
Other, 2006
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices

Practice addresses (Care Compare)

335 E Main St
Saint Anthony, ID 83445-1546
Phone (208) 356-4900

72 S 1St
Suite 101
Rexburg, ID 83440-1902
Phone (208) 356-4900

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled

State licenses

LicenseStateTypeSpecialty
LCSW 30350IDMDClinical Social Worker

Practice roles

OrganizationSpecialtyStatusNew patients
Upper Valley Community Health Services Inc Social Worker CurrentSince Feb 12, 2024 Accepting new patients
Upper Valley Community Health Services Inc Social Worker Past Accepting new patients
Upper Valley Community Health Services Inc Social Worker Past Accepting new patients

Locations

3729 Woodking Dr
#1
Idaho Falls, ID 83404
Phone (208) 522-3404

72 S 1st E
Ste 101
Rexburg, ID 83440

72 S 1st E
Ste 103
Rexburg, ID 83440

335 E Main St
Saint Anthony, ID 83445
Phone (208) 624-4100

335 E Main St
Ste 1
Saint Anthony, ID 83445

335 E Main St
Ste 3
Saint Anthony, ID 83445
Phone (208) 624-4100

Ownership & related parties

All facility ownership & control disclosures 4

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Grand Peaks Medical Or Grand Peaks Behavioral HealthRexburg, ID, CCN 131868 Federally qualified health center Corporate Director Aug 2, 2017
Grand Peaks Behavioral HealthSaint Anthony, ID, CCN 131878 Federally qualified health center W-2 Managing Employee Aug 2, 2017
Upper Valley Community Health Services IncIdaho Falls, ID, CCN 131044 Federally qualified health center Corporate Director Aug 2, 2017
Grand Peaks Medical Behavioral HealthDubois, ID, CCN 131051 Federally qualified health center W-2 Managing Employee Aug 2, 2017

Owned or controlled facilities with NPI records 5

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Organizations & group practices 4

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1366848000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1717372800000",
    "number": "1891139432",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 18",
            "city": "SAINT ANTHONY",
            "state": "ID",
            "postal_code": "834450018",
            "telephone_number": "208-356-4900",
            "fax_number": "208-624-4112"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "335 E MAIN ST STE 1",
            "city": "SAINT ANTHONY",
            "state": "ID",
            "postal_code": "834451546",
            "telephone_number": "208-356-4900",
            "fax_number": "208-624-4030"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "72 S 1st E Ste 101",
            "address_purpose": "LOCATION",
            "city": "Rexburg",
            "state": "ID",
            "postal_code": "834401965",
            "country_code": "US",
            "telephone_number": "208-356-4900",
            "fax_number": "208-624-4030",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "3729 Woodking Dr Ste 1",
            "address_purpose": "LOCATION",
            "city": "Idaho Falls",
            "state": "ID",
            "postal_code": "834044720",
            "country_code": "US",
            "telephone_number": "208-356-4900",
            "fax_number": "208-612-6118",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "BRADLEY",
        "first_name": "LARRY",
        "middle_name": "MILES",
        "credential": "LCSW",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2013-04-25",
        "last_updated": "2024-06-03",
        "certification_date": "2024-06-03",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "ID",
            "license": "LCSW 30350",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Saint Anthony, ID

Sources for this page

Verify at the official NPI Registry.