Provider Demographics
NPI:1164516191
Name:BRADLEY, KIMBERLY J (LBSW)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:J
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1933 MILES RD
Mailing Address - Street 2:
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-8042
Mailing Address - Country:US
Mailing Address - Phone:810-667-0500
Mailing Address - Fax:810-664-8728
Practice Address - Street 1:1570 SUNCREST DR
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-1154
Practice Address - Country:US
Practice Address - Phone:810-667-0500
Practice Address - Fax:810-664-8728
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6803075060104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1705242 TYPE 21Medicaid