Provider Demographics
NPI:1215195029
Name:BRADLEY, SALLIE M (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SALLIE
Middle Name:M
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27065
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93729-7065
Mailing Address - Country:US
Mailing Address - Phone:559-916-7585
Mailing Address - Fax:559-230-1799
Practice Address - Street 1:2519 W SHAW AVE
Practice Address - Street 2:SUITE #100
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3311
Practice Address - Country:US
Practice Address - Phone:559-230-1008
Practice Address - Fax:559-230-1799
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-28
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALW112491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS72149Medicare UPIN
CAZZZ17418ZMedicare PIN