Provider Demographics
NPI:1326788274
Name:BRADLEY, AMELIA
Entity Type:Individual
Prefix:
First Name:AMELIA
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 S CROSS RD
Mailing Address - Street 2:
Mailing Address - City:STAATSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:12580-6031
Mailing Address - Country:US
Mailing Address - Phone:781-414-1813
Mailing Address - Fax:
Practice Address - Street 1:339 N BROADWAY
Practice Address - Street 2:
Practice Address - City:NYACK
Practice Address - State:NY
Practice Address - Zip Code:10960-1522
Practice Address - Country:US
Practice Address - Phone:845-818-2733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-30
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2347475163WP0808X
NY404504363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health