Provider Demographics
NPI:1083763320
Name:BRADLEY, MICHAEL JOSEPH
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:MICHAEL
Other - Middle Name:JOSEPH
Other - Last Name:BRADLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:EDD
Mailing Address - Street 1:1200 BUSTLETON PIKE
Mailing Address - Street 2:SUITE 15-B
Mailing Address - City:FEASTERVILLE TREVOSE
Mailing Address - State:PA
Mailing Address - Zip Code:19053-4118
Mailing Address - Country:US
Mailing Address - Phone:215-355-2992
Mailing Address - Fax:215-355-2992
Practice Address - Street 1:1200 BUSTLETON PIKE
Practice Address - Street 2:SUITE 15-B
Practice Address - City:FEASTERVILLE TREVOSE
Practice Address - State:PA
Practice Address - Zip Code:19053-4118
Practice Address - Country:US
Practice Address - Phone:215-355-2992
Practice Address - Fax:215-355-2992
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA5234L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist