Provider Demographics
NPI:1326525890
Name:BRADLEY, ALYSSA R
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:R
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:R
Other - Last Name:FITZPATRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:962 MONARCH ST APT D
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-7273
Mailing Address - Country:US
Mailing Address - Phone:951-977-0327
Mailing Address - Fax:
Practice Address - Street 1:31772 CASINO DR STE B
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-4502
Practice Address - Country:US
Practice Address - Phone:951-977-0327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-26
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106426106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist