Provider Demographics
NPI:1003695776
Name:BRADLEY, ELISA K
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:K
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2030 W ELM ST
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-2654
Mailing Address - Country:US
Mailing Address - Phone:419-234-2134
Mailing Address - Fax:
Practice Address - Street 1:2963 BLUE JACKET CT
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45806-1464
Practice Address - Country:US
Practice Address - Phone:567-825-1192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-22
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2305414101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional