Provider Demographics
NPI:1245739358
Name:WEST, BRADLEY (MS, NCSP)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:WEST
Suffix:
Gender:M
Credentials:MS, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 CEDARWOOD DR
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-1313
Mailing Address - Country:US
Mailing Address - Phone:518-232-0885
Mailing Address - Fax:
Practice Address - Street 1:13 LOCUST ST
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-4544
Practice Address - Country:US
Practice Address - Phone:518-232-0885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-04
Last Update Date:2018-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool