Provider Demographics
NPI:1104397348
Name:BRADLEY, BRIAN K (AII2201214)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:K
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:AII2201214
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 S CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93702-2908
Mailing Address - Country:US
Mailing Address - Phone:559-600-9168
Mailing Address - Fax:
Practice Address - Street 1:2212 N WINERY AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93703-2896
Practice Address - Country:US
Practice Address - Phone:559-600-9168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAII2201214101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)