Provider Demographics
NPI:1326421801
Name:ADAMS, BRADLEY WAYNE SR
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:WAYNE
Last Name:ADAMS
Suffix:SR
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 1:23515 HIGHWAY 190
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-7334
Mailing Address - Country:US
Mailing Address - Phone:985-624-4100
Mailing Address - Fax:
Practice Address - Street 1:23515 HIGHWAY 190
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448-7334
Practice Address - Country:US
Practice Address - Phone:985-624-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-02
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA083102324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility