Provider Demographics
NPI:1225677826
Name:BRADLEY, NEILAN CRAIG
Entity Type:Individual
Prefix:
First Name:NEILAN
Middle Name:CRAIG
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1094 LUEHU ST
Mailing Address - Street 2:
Mailing Address - City:PEARL CITY
Mailing Address - State:HI
Mailing Address - Zip Code:96782-2620
Mailing Address - Country:US
Mailing Address - Phone:573-576-7072
Mailing Address - Fax:
Practice Address - Street 1:1094 LUEHU ST
Practice Address - Street 2:
Practice Address - City:PEARL CITY
Practice Address - State:HI
Practice Address - Zip Code:96782-2620
Practice Address - Country:US
Practice Address - Phone:573-576-7072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-30
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI551284106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician