Provider Demographics
NPI:1033268149
Name:BRADLEY, TERENCE LEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:TERENCE
Middle Name:LEE
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 1:12501 SW TORCH LAKE DR
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49676-9333
Mailing Address - Country:US
Mailing Address - Phone:231-883-3066
Mailing Address - Fax:
Practice Address - Street 1:3926 VILLAGE CIRCLE DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-6305
Practice Address - Country:US
Practice Address - Phone:231-938-5900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI002718103TC0700X
CACP11369103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP11369Medicare ID - Type Unspecified
MIOM10140Medicare ID - Type Unspecified
CAR16354Medicare UPIN