Provider Demographics
NPI:1003338039
Name:BRADLEY, EVAN MICHAEL (MS, BCBA, LBS)
Entity Type:Individual
Prefix:MR
First Name:EVAN
Middle Name:MICHAEL
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:MS, BCBA, LBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 W SOMERVILLE AVE APT 1019
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19141-2970
Mailing Address - Country:US
Mailing Address - Phone:267-972-1717
Mailing Address - Fax:
Practice Address - Street 1:4 NESHAMINY INTERPLEX DR STE 204
Practice Address - Street 2:
Practice Address - City:FEASTERVILLE TREVOSE
Practice Address - State:PA
Practice Address - Zip Code:19053-6940
Practice Address - Country:US
Practice Address - Phone:267-520-3301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-12
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH003470103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-17-25207OtherBEHAVIOR ANALYSIS CERTIFICATION BOARD
PABH003470OtherLICENSED BEHAVIOR SPECIALIST