Provider Demographics
NPI:1144571977
Name:BRADLEY, TYEISHA R
Entity Type:Individual
Prefix:
First Name:TYEISHA
Middle Name:R
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 MCANDREW RD
Mailing Address - Street 2:
Mailing Address - City:WAHIAWA
Mailing Address - State:HI
Mailing Address - Zip Code:96786-5819
Mailing Address - Country:US
Mailing Address - Phone:931-624-0885
Mailing Address - Fax:
Practice Address - Street 1:123 MCANDREW RD
Practice Address - Street 2:
Practice Address - City:WAHIAWA
Practice Address - State:HI
Practice Address - Zip Code:96786-5819
Practice Address - Country:US
Practice Address - Phone:931-624-0885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
HILCSW-43171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker