Provider Demographics
NPI:1164085544
Name:BRADLEY, ROBERT (LAC, LMBT)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:LAC, LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4425 BAYLOR ST STE E
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27455-2565
Mailing Address - Country:US
Mailing Address - Phone:910-813-6425
Mailing Address - Fax:
Practice Address - Street 1:3405 LEWISTON RD STE E
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-9827
Practice Address - Country:US
Practice Address - Phone:910-813-6425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-21
Last Update Date:2019-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1016171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist