Provider Demographics
NPI:1083018527
Name:RICHARDS, BRADLEY
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:
Last Name:RICHARDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SNAPDRAGON LN
Mailing Address - Street 2:
Mailing Address - City:ROSLYN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11577-2512
Mailing Address - Country:US
Mailing Address - Phone:516-721-7797
Mailing Address - Fax:
Practice Address - Street 1:1 SNAPDRAGON LN
Practice Address - Street 2:
Practice Address - City:ROSLYN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11577-2512
Practice Address - Country:US
Practice Address - Phone:516-721-7797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-13
Last Update Date:2016-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
NY000-554-1103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY983886503OtherDRIVER ID