Provider Demographics
NPI:1033243837
Name:BRADLEY, JOHN ROSS (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROSS
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1894
Mailing Address - Street 2:
Mailing Address - City:COLSTRIP
Mailing Address - State:MT
Mailing Address - Zip Code:59323-1894
Mailing Address - Country:US
Mailing Address - Phone:406-477-4514
Mailing Address - Fax:406-477-4513
Practice Address - Street 1:100 CHEYENNE AVE.
Practice Address - Street 2:
Practice Address - City:LAME DEER
Practice Address - State:MT
Practice Address - Zip Code:59043-0070
Practice Address - Country:US
Practice Address - Phone:406-477-4514
Practice Address - Fax:406-477-4513
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT168103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical