Provider Demographics
NPI:1184859647
Name:BRADLEY, LISA (MSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 W LINN ST
Mailing Address - Street 2:P.O. BOX 730
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-5837
Mailing Address - Country:US
Mailing Address - Phone:405-321-0022
Mailing Address - Fax:405-360-4918
Practice Address - Street 1:215 W LINN ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-5837
Practice Address - Country:US
Practice Address - Phone:405-321-0022
Practice Address - Fax:405-360-4918
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-27
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1629130166Medicaid